| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,064 |
3,018 |
$135K |
| D9248 |
|
509 |
418 |
$94K |
| D1206 |
Topical application of fluoride varnish |
3,655 |
3,600 |
$91K |
| D0120 |
Periodic oral evaluation - established patient |
2,883 |
2,835 |
$86K |
| D7140 |
Extraction, erupted tooth or exposed root |
710 |
354 |
$72K |
| D1351 |
Sealant - per tooth |
1,868 |
456 |
$63K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
484 |
227 |
$58K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,001 |
986 |
$24K |
| D1330 |
|
2,176 |
2,145 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
1,286 |
1,261 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
216 |
212 |
$11K |
| D2394 |
|
29 |
15 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
58 |
55 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
20 |
12 |
$2K |
| D0274 |
Bitewings - four radiographic images |
55 |
54 |
$1K |
| D1110 |
Prophylaxis - adult |
15 |
15 |
$927.06 |
| D0272 |
Bitewings - two radiographic images |
49 |
49 |
$735.00 |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$684.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
20 |
16 |
$342.00 |
| D0240 |
|
14 |
14 |
$243.00 |