| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
4,006 |
3,956 |
$214K |
| D1206 |
Topical application of fluoride varnish |
5,806 |
5,739 |
$158K |
| D0120 |
Periodic oral evaluation - established patient |
4,954 |
4,901 |
$150K |
| D1110 |
Prophylaxis - adult |
1,330 |
1,318 |
$96K |
| D0272 |
Bitewings - two radiographic images |
1,325 |
1,310 |
$41K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
192 |
129 |
$23K |
| D1351 |
Sealant - per tooth |
185 |
46 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
98 |
98 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
19 |
12 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
53 |
53 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
51 |
50 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$581.00 |
| D0220 |
Intraoral - periapical first radiographic image |
27 |
27 |
$567.00 |