| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,149 |
2,133 |
$90K |
| D1206 |
Topical application of fluoride varnish |
2,143 |
2,127 |
$57K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
869 |
561 |
$57K |
| D0120 |
Periodic oral evaluation - established patient |
1,726 |
1,716 |
$50K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
534 |
387 |
$24K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
192 |
181 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
469 |
463 |
$12K |
| D0274 |
Bitewings - four radiographic images |
619 |
615 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
1,094 |
1,081 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,044 |
954 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
56 |
47 |
$5K |
| D0272 |
Bitewings - two radiographic images |
331 |
329 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
58 |
39 |
$3K |
| D1351 |
Sealant - per tooth |
54 |
16 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
45 |
45 |
$764.80 |