| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,668 |
2,647 |
$128K |
| D1206 |
Topical application of fluoride varnish |
2,861 |
2,839 |
$74K |
| D0120 |
Periodic oral evaluation - established patient |
2,296 |
2,279 |
$72K |
| D1351 |
Sealant - per tooth |
1,296 |
317 |
$51K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
144 |
107 |
$20K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
312 |
309 |
$17K |
| D0272 |
Bitewings - two radiographic images |
956 |
952 |
$16K |
| D1330 |
|
1,499 |
1,483 |
$10K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
486 |
449 |
$10K |
| D0330 |
Panoramic radiographic image |
163 |
163 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
50 |
36 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
134 |
132 |
$6K |
| D3120 |
|
104 |
75 |
$4K |
| D0145 |
Oral evaluation for a patient under three years of age |
56 |
56 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
135 |
135 |
$2K |
| D0274 |
Bitewings - four radiographic images |
44 |
44 |
$1K |
| D0240 |
|
39 |
39 |
$693.00 |