| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,055 |
2,047 |
$70K |
| D0120 |
Periodic oral evaluation - established patient |
2,352 |
2,346 |
$56K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,420 |
2,412 |
$38K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
227 |
133 |
$15K |
| D1351 |
Sealant - per tooth |
568 |
178 |
$14K |
| D0272 |
Bitewings - two radiographic images |
811 |
806 |
$13K |
| D1110 |
Prophylaxis - adult |
266 |
266 |
$10K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
385 |
332 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
401 |
395 |
$4K |
| D0274 |
Bitewings - four radiographic images |
160 |
160 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
66 |
64 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
48 |
46 |
$2K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
21 |
12 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
15 |
12 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
130 |
78 |
$963.00 |
| D1354 |
|
211 |
39 |
$490.00 |
| D1999 |
|
37 |
36 |
$182.00 |
| D1203 |
|
14 |
14 |
$0.00 |
| D1330 |
|
15 |
13 |
$0.00 |