| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,579 |
3,579 |
$114K |
| D0120 |
Periodic oral evaluation - established patient |
3,354 |
3,354 |
$74K |
| D1206 |
Topical application of fluoride varnish |
1,853 |
1,853 |
$46K |
| D1351 |
Sealant - per tooth |
816 |
396 |
$44K |
| D0272 |
Bitewings - two radiographic images |
2,747 |
2,747 |
$34K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
506 |
409 |
$30K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,015 |
2,015 |
$22K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
417 |
417 |
$9K |
| D0240 |
|
219 |
219 |
$5K |
| D0330 |
Panoramic radiographic image |
199 |
199 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
113 |
97 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
174 |
174 |
$4K |
| D1110 |
Prophylaxis - adult |
83 |
83 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
126 |
126 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
35 |
31 |
$1K |
| D0274 |
Bitewings - four radiographic images |
62 |
62 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
79 |
78 |
$842.45 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
33 |
33 |
$540.00 |
| D1999 |
|
42 |
42 |
$0.00 |