| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,280 |
1,273 |
$54K |
| D1206 |
Topical application of fluoride varnish |
1,298 |
1,290 |
$39K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
433 |
250 |
$38K |
| D0120 |
Periodic oral evaluation - established patient |
1,083 |
1,075 |
$26K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
486 |
431 |
$12K |
| D1351 |
Sealant - per tooth |
485 |
117 |
$12K |
| D0272 |
Bitewings - two radiographic images |
556 |
553 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
101 |
66 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
119 |
119 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
480 |
473 |
$5K |
| D0603 |
|
289 |
286 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
320 |
320 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
22 |
15 |
$1K |
| D0274 |
Bitewings - four radiographic images |
34 |
34 |
$1K |
| D1310 |
|
94 |
94 |
$928.00 |
| D0602 |
|
39 |
39 |
$390.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$300.00 |
| D0273 |
|
25 |
25 |
$249.00 |
| D0601 |
|
12 |
12 |
$90.00 |
| D1330 |
|
15 |
15 |
$0.00 |