| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,930 |
1,928 |
$78K |
| D1206 |
Topical application of fluoride varnish |
2,340 |
2,337 |
$61K |
| D0120 |
Periodic oral evaluation - established patient |
2,159 |
2,156 |
$57K |
| D1351 |
Sealant - per tooth |
1,477 |
292 |
$44K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
380 |
270 |
$24K |
| D1110 |
Prophylaxis - adult |
489 |
487 |
$18K |
| D0272 |
Bitewings - two radiographic images |
807 |
803 |
$14K |
| D0603 |
|
1,311 |
1,310 |
$13K |
| D0274 |
Bitewings - four radiographic images |
380 |
380 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
200 |
157 |
$10K |
| D0330 |
Panoramic radiographic image |
215 |
215 |
$9K |
| D7140 |
Extraction, erupted tooth or exposed root |
100 |
72 |
$6K |
| D1330 |
|
968 |
967 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
375 |
371 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
77 |
76 |
$2K |
| D1353 |
|
140 |
26 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
58 |
53 |
$1K |
| D0602 |
|
135 |
135 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
35 |
34 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
160 |
152 |
$955.36 |
| D9920 |
|
24 |
24 |
$595.00 |
| D0240 |
|
19 |
14 |
$374.28 |