| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
1,023 |
1,006 |
$35K |
| D1120 |
Prophylaxis - child |
910 |
905 |
$32K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
327 |
321 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
493 |
491 |
$8K |
| D1351 |
Sealant - per tooth |
191 |
61 |
$4K |
| D0272 |
Bitewings - two radiographic images |
156 |
152 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
62 |
59 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
54 |
32 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
39 |
33 |
$1K |
| D0240 |
|
50 |
50 |
$980.00 |
| D7140 |
Extraction, erupted tooth or exposed root |
19 |
12 |
$741.00 |
| D0220 |
Intraoral - periapical first radiographic image |
56 |
56 |
$560.00 |
| D1110 |
Prophylaxis - adult |
17 |
17 |
$510.00 |
| D0274 |
Bitewings - four radiographic images |
15 |
12 |
$476.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
48 |
48 |
$413.00 |