| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,891 |
3,888 |
$169K |
| D1206 |
Topical application of fluoride varnish |
4,207 |
4,203 |
$129K |
| D1351 |
Sealant - per tooth |
6,142 |
1,542 |
$119K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,513 |
791 |
$104K |
| D0120 |
Periodic oral evaluation - established patient |
3,790 |
3,786 |
$94K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,495 |
1,469 |
$37K |
| D1353 |
|
3,624 |
838 |
$31K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
499 |
337 |
$27K |
| D0272 |
Bitewings - two radiographic images |
1,724 |
1,723 |
$17K |
| D1110 |
Prophylaxis - adult |
301 |
301 |
$13K |
| D0603 |
|
1,656 |
1,653 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
2,455 |
2,451 |
$11K |
| D0274 |
Bitewings - four radiographic images |
938 |
938 |
$11K |
| D7140 |
Extraction, erupted tooth or exposed root |
109 |
67 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
78 |
56 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,141 |
2,133 |
$6K |
| D0601 |
|
727 |
725 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
115 |
115 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
28 |
28 |
$1K |
| D0145 |
Oral evaluation for a patient under three years of age |
13 |
13 |
$580.00 |
| D0602 |
|
68 |
68 |
$480.00 |