| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,239 |
3,223 |
$166K |
| D1206 |
Topical application of fluoride varnish |
3,558 |
3,540 |
$94K |
| D0120 |
Periodic oral evaluation - established patient |
2,718 |
2,703 |
$80K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
194 |
90 |
$23K |
| D0272 |
Bitewings - two radiographic images |
353 |
353 |
$11K |
| D0274 |
Bitewings - four radiographic images |
236 |
235 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
167 |
167 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
336 |
331 |
$7K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
292 |
282 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
202 |
98 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
18 |
12 |
$2K |
| D1351 |
Sealant - per tooth |
37 |
13 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
34 |
34 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
17 |
13 |
$1K |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$900.00 |
| D1330 |
|
3,610 |
3,587 |
$0.00 |
| D1999 |
|
326 |
312 |
$0.00 |