| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
5,225 |
5,221 |
$231K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,040 |
1,438 |
$210K |
| D1208 |
Topical application of fluoride, excluding varnish |
5,553 |
5,549 |
$138K |
| D0120 |
Periodic oral evaluation - established patient |
4,825 |
4,822 |
$120K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,314 |
798 |
$72K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,150 |
790 |
$50K |
| D1351 |
Sealant - per tooth |
1,632 |
347 |
$33K |
| D0272 |
Bitewings - two radiographic images |
2,112 |
2,112 |
$21K |
| D0601 |
|
2,099 |
2,095 |
$21K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
142 |
97 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
424 |
423 |
$10K |
| D1110 |
Prophylaxis - adult |
75 |
75 |
$3K |
| D0603 |
|
330 |
330 |
$3K |
| D0602 |
|
270 |
270 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
90 |
85 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
86 |
83 |
$2K |
| D9248 |
|
13 |
12 |
$2K |
| D0274 |
Bitewings - four radiographic images |
72 |
72 |
$864.00 |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$507.50 |