| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,018 |
2,919 |
$20K |
| D1206 |
Topical application of fluoride varnish |
2,459 |
2,415 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
3,204 |
3,108 |
$9K |
| D0272 |
Bitewings - two radiographic images |
1,237 |
1,195 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
192 |
91 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
742 |
671 |
$1K |
| D1110 |
Prophylaxis - adult |
360 |
354 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
161 |
98 |
$818.73 |
| D0330 |
Panoramic radiographic image |
130 |
130 |
$818.36 |
| D1351 |
Sealant - per tooth |
436 |
129 |
$815.92 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
89 |
82 |
$458.20 |
| D0240 |
|
197 |
99 |
$396.99 |
| D0274 |
Bitewings - four radiographic images |
114 |
110 |
$391.01 |
| D0220 |
Intraoral - periapical first radiographic image |
135 |
126 |
$191.36 |
| D1208 |
Topical application of fluoride, excluding varnish |
1,088 |
1,022 |
$55.00 |
| D1999 |
|
24 |
24 |
$0.00 |
| D0210 |
Intraoral - complete series of radiographic images |
14 |
12 |
$0.00 |
| D9248 |
|
16 |
13 |
$0.00 |
| D7140 |
Extraction, erupted tooth or exposed root |
26 |
12 |
$0.00 |