| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,813 |
2,811 |
$71K |
| D1206 |
Topical application of fluoride varnish |
3,123 |
2,925 |
$64K |
| D0120 |
Periodic oral evaluation - established patient |
2,922 |
2,921 |
$63K |
| D1351 |
Sealant - per tooth |
1,306 |
320 |
$32K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
345 |
234 |
$25K |
| D0272 |
Bitewings - two radiographic images |
2,036 |
2,035 |
$22K |
| D0240 |
|
2,076 |
1,444 |
$18K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
615 |
573 |
$16K |
| D0210 |
Intraoral - complete series of radiographic images |
344 |
344 |
$16K |
| D0274 |
Bitewings - four radiographic images |
648 |
648 |
$10K |
| D1110 |
Prophylaxis - adult |
219 |
218 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
133 |
72 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
209 |
208 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
171 |
171 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
108 |
108 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
34 |
27 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
230 |
228 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
112 |
97 |
$530.00 |
| D0330 |
Panoramic radiographic image |
452 |
452 |
$468.72 |