| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
5,268 |
5,266 |
$222K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
5,755 |
5,751 |
$148K |
| D1351 |
Sealant - per tooth |
1,925 |
1,134 |
$147K |
| D1206 |
Topical application of fluoride varnish |
5,176 |
5,174 |
$139K |
| D0120 |
Periodic oral evaluation - established patient |
3,807 |
3,806 |
$108K |
| D0272 |
Bitewings - two radiographic images |
6,807 |
6,800 |
$69K |
| D0220 |
Intraoral - periapical first radiographic image |
7,382 |
7,358 |
$46K |
| D0230 |
Intraoral - periapical each additional radiographic image |
7,006 |
6,966 |
$30K |
| D0210 |
Intraoral - complete series of radiographic images |
1,120 |
1,120 |
$28K |
| D1354 |
|
1,010 |
788 |
$25K |
| D0330 |
Panoramic radiographic image |
957 |
954 |
$20K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
269 |
261 |
$16K |
| D0140 |
Limited oral evaluation - problem focused |
829 |
819 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
122 |
75 |
$9K |
| D0274 |
Bitewings - four radiographic images |
492 |
492 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
84 |
66 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
16 |
14 |
$963.90 |