| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
13,445 |
13,444 |
$536K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
3,616 |
3,284 |
$531K |
| D0120 |
Periodic oral evaluation - established patient |
16,012 |
16,010 |
$439K |
| D1351 |
Sealant - per tooth |
7,414 |
2,324 |
$273K |
| D1206 |
Topical application of fluoride varnish |
8,178 |
8,177 |
$233K |
| D1110 |
Prophylaxis - adult |
4,015 |
4,015 |
$214K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,390 |
1,835 |
$206K |
| D1208 |
Topical application of fluoride, excluding varnish |
10,815 |
10,815 |
$153K |
| D0330 |
Panoramic radiographic image |
2,440 |
2,440 |
$125K |
| D0272 |
Bitewings - two radiographic images |
4,852 |
4,851 |
$100K |
| D0274 |
Bitewings - four radiographic images |
1,515 |
1,515 |
$56K |
| D7140 |
Extraction, erupted tooth or exposed root |
962 |
671 |
$54K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
420 |
389 |
$44K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,334 |
1,334 |
$38K |
| D0220 |
Intraoral - periapical first radiographic image |
1,003 |
971 |
$13K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
32 |
25 |
$2K |
| D1354 |
|
23 |
12 |
$863.55 |
| D9110 |
|
19 |
19 |
$526.15 |
| D0240 |
|
12 |
12 |
$193.80 |
| D1999 |
|
7,026 |
6,744 |
$0.00 |
| D9995 |
|
19 |
19 |
$0.00 |