| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
6,312 |
6,198 |
$167K |
| D1206 |
Topical application of fluoride varnish |
9,155 |
8,983 |
$147K |
| D0120 |
Periodic oral evaluation - established patient |
8,542 |
8,382 |
$133K |
| D1110 |
Prophylaxis - adult |
2,231 |
2,195 |
$80K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
782 |
762 |
$22K |
| D0272 |
Bitewings - two radiographic images |
783 |
772 |
$14K |
| D1351 |
Sealant - per tooth |
239 |
74 |
$8K |
| D9630 |
|
421 |
399 |
$8K |
| D0274 |
Bitewings - four radiographic images |
362 |
361 |
$8K |
| D0330 |
Panoramic radiographic image |
81 |
81 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
67 |
26 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
365 |
331 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
114 |
114 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
31 |
25 |
$3K |
| D9310 |
|
12 |
12 |
$998.28 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$322.79 |
| D0240 |
|
14 |
13 |
$171.78 |