| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,991 |
1,972 |
$48K |
| D1206 |
Topical application of fluoride varnish |
2,425 |
2,404 |
$37K |
| D0120 |
Periodic oral evaluation - established patient |
1,592 |
1,575 |
$21K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
618 |
551 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
125 |
74 |
$7K |
| D0272 |
Bitewings - two radiographic images |
435 |
426 |
$6K |
| D0240 |
|
440 |
220 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
106 |
106 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
46 |
27 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
160 |
160 |
$624.79 |
| D1110 |
Prophylaxis - adult |
88 |
88 |
$0.00 |
| D1351 |
Sealant - per tooth |
176 |
54 |
$0.00 |
| D3120 |
|
34 |
15 |
$0.00 |
| D7140 |
Extraction, erupted tooth or exposed root |
35 |
26 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
13 |
13 |
$0.00 |