| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,415 |
1,411 |
$62K |
| D1351 |
Sealant - per tooth |
2,461 |
591 |
$47K |
| D1206 |
Topical application of fluoride varnish |
1,487 |
1,485 |
$45K |
| D0120 |
Periodic oral evaluation - established patient |
1,248 |
1,246 |
$31K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
420 |
258 |
$28K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
331 |
215 |
$18K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
521 |
509 |
$13K |
| D1353 |
|
1,179 |
263 |
$11K |
| D0272 |
Bitewings - two radiographic images |
704 |
704 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
1,283 |
1,276 |
$6K |
| D0603 |
|
693 |
688 |
$5K |
| D0274 |
Bitewings - four radiographic images |
338 |
337 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
59 |
38 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
157 |
157 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,206 |
1,200 |
$4K |
| D1110 |
Prophylaxis - adult |
50 |
50 |
$1K |
| D0601 |
|
154 |
154 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
32 |
31 |
$1K |
| D0602 |
|
71 |
70 |
$660.00 |