| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,402 |
2,402 |
$124K |
| D0120 |
Periodic oral evaluation - established patient |
1,099 |
1,099 |
$80K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,030 |
1,030 |
$69K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
646 |
452 |
$43K |
| D1206 |
Topical application of fluoride varnish |
2,155 |
2,155 |
$43K |
| D0230 |
Intraoral - periapical each additional radiographic image |
7,668 |
2,315 |
$31K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
786 |
657 |
$31K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
275 |
209 |
$15K |
| D0274 |
Bitewings - four radiographic images |
544 |
544 |
$12K |
| D0272 |
Bitewings - two radiographic images |
963 |
963 |
$11K |
| D0145 |
Oral evaluation for a patient under three years of age |
130 |
130 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
619 |
590 |
$7K |
| D1351 |
Sealant - per tooth |
126 |
77 |
$5K |
| D0330 |
Panoramic radiographic image |
120 |
120 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
57 |
44 |
$3K |
| D1352 |
|
25 |
17 |
$962.50 |
| D0350 |
|
55 |
45 |
$528.00 |
| D9430 |
|
12 |
12 |
$384.00 |