| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,073 |
2,073 |
$72K |
| D1206 |
Topical application of fluoride varnish |
1,871 |
1,871 |
$45K |
| D0120 |
Periodic oral evaluation - established patient |
1,266 |
1,266 |
$29K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
846 |
846 |
$20K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
283 |
195 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
1,183 |
1,169 |
$13K |
| D0272 |
Bitewings - two radiographic images |
950 |
948 |
$13K |
| D1351 |
Sealant - per tooth |
171 |
79 |
$7K |
| D9990 |
|
302 |
275 |
$7K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
204 |
182 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
949 |
947 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
152 |
92 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
95 |
80 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
207 |
207 |
$2K |
| D0274 |
Bitewings - four radiographic images |
60 |
60 |
$1K |
| D0330 |
Panoramic radiographic image |
33 |
33 |
$1K |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$557.70 |