| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
5,734 |
5,730 |
$243K |
| D0120 |
Periodic oral evaluation - established patient |
5,335 |
5,331 |
$155K |
| D1206 |
Topical application of fluoride varnish |
5,484 |
5,480 |
$148K |
| D1351 |
Sealant - per tooth |
1,799 |
1,229 |
$148K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
992 |
848 |
$72K |
| D0274 |
Bitewings - four radiographic images |
2,228 |
2,223 |
$41K |
| D0220 |
Intraoral - periapical first radiographic image |
4,732 |
4,693 |
$31K |
| D7140 |
Extraction, erupted tooth or exposed root |
410 |
361 |
$27K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,035 |
1,031 |
$26K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,479 |
4,328 |
$24K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
361 |
335 |
$17K |
| D1110 |
Prophylaxis - adult |
319 |
318 |
$15K |
| D4341 |
|
64 |
42 |
$15K |
| D0140 |
Limited oral evaluation - problem focused |
660 |
652 |
$12K |
| D0272 |
Bitewings - two radiographic images |
1,059 |
1,058 |
$12K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
83 |
71 |
$8K |
| D4342 |
|
26 |
13 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
40 |
39 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
63 |
63 |
$2K |
| D0330 |
Panoramic radiographic image |
14 |
14 |
$330.32 |
| D9310 |
|
12 |
12 |
$171.00 |