| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,523 |
2,523 |
$106K |
| D1206 |
Topical application of fluoride varnish |
2,337 |
2,337 |
$62K |
| D0120 |
Periodic oral evaluation - established patient |
2,016 |
2,016 |
$58K |
| D1351 |
Sealant - per tooth |
750 |
334 |
$46K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
691 |
535 |
$43K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
466 |
438 |
$31K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
757 |
757 |
$19K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
411 |
358 |
$17K |
| D7140 |
Extraction, erupted tooth or exposed root |
241 |
217 |
$14K |
| D0274 |
Bitewings - four radiographic images |
560 |
560 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
1,538 |
1,532 |
$10K |
| D0272 |
Bitewings - two radiographic images |
741 |
741 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,286 |
1,285 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
320 |
317 |
$6K |
| D1110 |
Prophylaxis - adult |
57 |
57 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
17 |
14 |
$1K |
| D0270 |
|
14 |
14 |
$78.40 |