| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,711 |
1,699 |
$111K |
| D1120 |
Prophylaxis - child |
2,299 |
2,283 |
$94K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,349 |
1,184 |
$53K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
527 |
332 |
$32K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
490 |
490 |
$32K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,141 |
2,127 |
$31K |
| D1351 |
Sealant - per tooth |
801 |
200 |
$22K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,639 |
2,369 |
$18K |
| D0272 |
Bitewings - two radiographic images |
1,306 |
1,306 |
$15K |
| D0274 |
Bitewings - four radiographic images |
697 |
689 |
$15K |
| D1206 |
Topical application of fluoride varnish |
143 |
143 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
20 |
12 |
$918.40 |
| D0220 |
Intraoral - periapical first radiographic image |
55 |
53 |
$600.00 |
| D0350 |
|
58 |
27 |
$489.60 |
| D9430 |
|
15 |
13 |
$480.00 |