| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
4,295 |
4,264 |
$202K |
| D1206 |
Topical application of fluoride varnish |
4,534 |
4,503 |
$116K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
721 |
389 |
$95K |
| D0120 |
Periodic oral evaluation - established patient |
2,876 |
2,859 |
$90K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,635 |
1,619 |
$89K |
| D7140 |
Extraction, erupted tooth or exposed root |
621 |
373 |
$75K |
| D0140 |
Limited oral evaluation - problem focused |
950 |
907 |
$44K |
| D1351 |
Sealant - per tooth |
1,129 |
237 |
$44K |
| D0330 |
Panoramic radiographic image |
694 |
686 |
$31K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,159 |
1,065 |
$22K |
| D1330 |
|
2,786 |
2,762 |
$19K |
| D0272 |
Bitewings - two radiographic images |
1,091 |
1,083 |
$17K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
88 |
55 |
$9K |
| D0274 |
Bitewings - four radiographic images |
362 |
357 |
$8K |
| D3120 |
|
99 |
68 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
276 |
272 |
$3K |
| D1110 |
Prophylaxis - adult |
43 |
43 |
$3K |
| D1354 |
|
189 |
52 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
44 |
42 |
$966.00 |