| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
5,581 |
5,581 |
$251K |
| D1206 |
Topical application of fluoride varnish |
5,695 |
5,695 |
$178K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,745 |
1,177 |
$122K |
| D0120 |
Periodic oral evaluation - established patient |
4,807 |
4,807 |
$120K |
| D1351 |
Sealant - per tooth |
5,905 |
1,725 |
$118K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,254 |
895 |
$69K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,409 |
2,300 |
$60K |
| D0603 |
|
3,828 |
3,828 |
$38K |
| D7140 |
Extraction, erupted tooth or exposed root |
697 |
489 |
$35K |
| D0272 |
Bitewings - two radiographic images |
3,342 |
3,340 |
$33K |
| D1353 |
|
2,761 |
657 |
$28K |
| D0220 |
Intraoral - periapical first radiographic image |
4,880 |
4,871 |
$24K |
| D9920 |
|
934 |
932 |
$23K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,569 |
4,569 |
$15K |
| D0140 |
Limited oral evaluation - problem focused |
313 |
312 |
$14K |
| D0145 |
Oral evaluation for a patient under three years of age |
437 |
437 |
$12K |
| D0274 |
Bitewings - four radiographic images |
658 |
658 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
194 |
194 |
$5K |
| D0602 |
|
14 |
14 |
$140.00 |