| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
4,684 |
4,684 |
$208K |
| D1206 |
Topical application of fluoride varnish |
4,737 |
4,737 |
$148K |
| D0120 |
Periodic oral evaluation - established patient |
4,280 |
4,280 |
$107K |
| D0272 |
Bitewings - two radiographic images |
1,796 |
1,796 |
$18K |
| D0603 |
|
1,454 |
1,454 |
$14K |
| D9920 |
|
497 |
497 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
2,400 |
2,397 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
405 |
405 |
$10K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
340 |
322 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,189 |
2,189 |
$7K |
| D0602 |
|
570 |
570 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
48 |
36 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
26 |
12 |
$2K |
| D1351 |
Sealant - per tooth |
48 |
12 |
$960.00 |
| D0601 |
|
83 |
83 |
$830.00 |
| D0274 |
Bitewings - four radiographic images |
17 |
17 |
$204.00 |