| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
7,699 |
7,678 |
$259K |
| D1206 |
Topical application of fluoride varnish |
10,990 |
10,965 |
$215K |
| D0120 |
Periodic oral evaluation - established patient |
8,795 |
8,770 |
$212K |
| D1351 |
Sealant - per tooth |
3,721 |
1,181 |
$125K |
| D1110 |
Prophylaxis - adult |
2,032 |
2,026 |
$92K |
| D0272 |
Bitewings - two radiographic images |
3,872 |
3,865 |
$81K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
651 |
326 |
$80K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,471 |
1,435 |
$46K |
| D0220 |
Intraoral - periapical first radiographic image |
1,687 |
1,673 |
$22K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
538 |
538 |
$22K |
| D0145 |
Oral evaluation for a patient under three years of age |
457 |
457 |
$15K |
| D0274 |
Bitewings - four radiographic images |
424 |
424 |
$13K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
114 |
77 |
$11K |
| D0330 |
Panoramic radiographic image |
147 |
147 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
373 |
372 |
$6K |
| D1354 |
|
595 |
273 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
19 |
12 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$423.96 |