| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
4,917 |
4,916 |
$213K |
| D0120 |
Periodic oral evaluation - established patient |
7,160 |
7,160 |
$209K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,986 |
1,145 |
$168K |
| D1110 |
Prophylaxis - adult |
2,697 |
2,697 |
$156K |
| D1208 |
Topical application of fluoride, excluding varnish |
5,562 |
5,562 |
$78K |
| D1206 |
Topical application of fluoride varnish |
1,891 |
1,891 |
$57K |
| D0274 |
Bitewings - four radiographic images |
1,627 |
1,627 |
$48K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
721 |
458 |
$40K |
| D0272 |
Bitewings - two radiographic images |
1,743 |
1,743 |
$30K |
| D1351 |
Sealant - per tooth |
622 |
208 |
$27K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
161 |
125 |
$17K |
| D0330 |
Panoramic radiographic image |
417 |
417 |
$17K |
| D7140 |
Extraction, erupted tooth or exposed root |
160 |
98 |
$8K |
| D9990 |
|
417 |
413 |
$8K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
161 |
151 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
126 |
126 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
31 |
31 |
$434.00 |