| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,435 |
3,435 |
$132K |
| D0120 |
Periodic oral evaluation - established patient |
3,743 |
3,743 |
$98K |
| D1206 |
Topical application of fluoride varnish |
3,527 |
3,527 |
$93K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
704 |
387 |
$53K |
| D0272 |
Bitewings - two radiographic images |
2,227 |
2,227 |
$33K |
| D1110 |
Prophylaxis - adult |
394 |
394 |
$21K |
| D0220 |
Intraoral - periapical first radiographic image |
537 |
536 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
428 |
428 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
135 |
135 |
$4K |
| D0240 |
|
127 |
127 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
31 |
16 |
$2K |
| D1351 |
Sealant - per tooth |
33 |
14 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
30 |
14 |
$1K |
| D0274 |
Bitewings - four radiographic images |
41 |
41 |
$897.26 |
| D0230 |
Intraoral - periapical each additional radiographic image |
52 |
52 |
$392.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
24 |
24 |
$23.00 |