| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
4,389 |
4,364 |
$124K |
| D0120 |
Periodic oral evaluation - established patient |
3,952 |
3,929 |
$123K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,161 |
581 |
$106K |
| D1120 |
Prophylaxis - child |
1,928 |
1,920 |
$65K |
| D0274 |
Bitewings - four radiographic images |
1,776 |
1,772 |
$57K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
628 |
366 |
$47K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,686 |
1,219 |
$37K |
| D0220 |
Intraoral - periapical first radiographic image |
2,481 |
2,423 |
$37K |
| D1110 |
Prophylaxis - adult |
742 |
732 |
$34K |
| D9420 |
|
67 |
67 |
$10K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
358 |
340 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
97 |
93 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
43 |
24 |
$3K |
| D1351 |
Sealant - per tooth |
120 |
40 |
$2K |
| D4346 |
|
12 |
12 |
$990.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
29 |
28 |
$912.95 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$526.50 |
| D1999 |
|
420 |
369 |
$28.00 |
| D0603 |
|
59 |
59 |
$0.00 |