| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
563 |
559 |
$24K |
| D1206 |
Topical application of fluoride varnish |
580 |
576 |
$20K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
121 |
85 |
$13K |
| D0120 |
Periodic oral evaluation - established patient |
554 |
549 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
98 |
67 |
$7K |
| D0272 |
Bitewings - two radiographic images |
188 |
186 |
$4K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
121 |
116 |
$4K |
| D1351 |
Sealant - per tooth |
64 |
16 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
24 |
16 |
$2K |
| D1310 |
|
55 |
55 |
$2K |
| D1330 |
|
52 |
52 |
$2K |
| D0274 |
Bitewings - four radiographic images |
47 |
43 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
39 |
39 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
51 |
51 |
$751.00 |
| D0240 |
|
13 |
13 |
$600.00 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$396.00 |