| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
4,582 |
4,568 |
$194K |
| D1206 |
Topical application of fluoride varnish |
4,556 |
4,543 |
$157K |
| D0120 |
Periodic oral evaluation - established patient |
4,356 |
4,343 |
$90K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
596 |
446 |
$63K |
| D1351 |
Sealant - per tooth |
1,691 |
509 |
$56K |
| D0272 |
Bitewings - two radiographic images |
1,959 |
1,956 |
$47K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
562 |
416 |
$43K |
| D7140 |
Extraction, erupted tooth or exposed root |
219 |
162 |
$19K |
| D1110 |
Prophylaxis - adult |
252 |
252 |
$15K |
| D0330 |
Panoramic radiographic image |
203 |
203 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
337 |
335 |
$12K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
359 |
352 |
$11K |
| D0274 |
Bitewings - four radiographic images |
252 |
252 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
279 |
276 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
106 |
106 |
$3K |
| D0240 |
|
54 |
54 |
$2K |
| D7111 |
|
15 |
12 |
$750.00 |