| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
4,959 |
4,956 |
$175K |
| D1206 |
Topical application of fluoride varnish |
7,544 |
7,535 |
$152K |
| D0120 |
Periodic oral evaluation - established patient |
5,862 |
5,855 |
$145K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,099 |
726 |
$142K |
| D1110 |
Prophylaxis - adult |
1,756 |
1,753 |
$83K |
| D1351 |
Sealant - per tooth |
2,103 |
718 |
$77K |
| D0240 |
|
3,532 |
3,525 |
$71K |
| D0272 |
Bitewings - two radiographic images |
3,035 |
3,033 |
$65K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
604 |
402 |
$60K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,850 |
1,760 |
$58K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,362 |
1,362 |
$56K |
| D0210 |
Intraoral - complete series of radiographic images |
674 |
671 |
$56K |
| D0274 |
Bitewings - four radiographic images |
817 |
814 |
$26K |
| D0220 |
Intraoral - periapical first radiographic image |
746 |
742 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
489 |
489 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
39 |
26 |
$4K |
| D1354 |
|
139 |
50 |
$946.92 |
| D0145 |
Oral evaluation for a patient under three years of age |
28 |
28 |
$897.12 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$411.60 |