| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,344 |
2,336 |
$27K |
| D1351 |
Sealant - per tooth |
1,635 |
536 |
$19K |
| D1206 |
Topical application of fluoride varnish |
2,604 |
2,597 |
$18K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
726 |
480 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,440 |
1,438 |
$17K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,130 |
1,029 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,229 |
1,128 |
$12K |
| D0240 |
|
2,335 |
1,176 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
627 |
388 |
$10K |
| D0330 |
Panoramic radiographic image |
529 |
527 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
355 |
226 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
1,037 |
1,033 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
1,462 |
1,420 |
$5K |
| D0272 |
Bitewings - two radiographic images |
78 |
78 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
120 |
119 |
$1K |
| D1110 |
Prophylaxis - adult |
262 |
261 |
$1K |
| D0274 |
Bitewings - four radiographic images |
242 |
242 |
$466.44 |
| D3120 |
|
73 |
57 |
$0.00 |
| D0140 |
Limited oral evaluation - problem focused |
81 |
78 |
$0.00 |
| D9630 |
|
20 |
20 |
$0.00 |