| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
4,922 |
3,559 |
$83K |
| D1351 |
Sealant - per tooth |
3,949 |
534 |
$67K |
| D1206 |
Topical application of fluoride varnish |
4,620 |
3,357 |
$65K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,270 |
2,097 |
$55K |
| D0120 |
Periodic oral evaluation - established patient |
1,755 |
1,477 |
$37K |
| D8670 |
Periodic orthodontic treatment visit |
550 |
259 |
$26K |
| D0330 |
Panoramic radiographic image |
1,079 |
865 |
$23K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
354 |
135 |
$20K |
| D0210 |
Intraoral - complete series of radiographic images |
585 |
389 |
$18K |
| D0274 |
Bitewings - four radiographic images |
1,244 |
951 |
$17K |
| D0140 |
Limited oral evaluation - problem focused |
377 |
319 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
1,699 |
1,293 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,331 |
904 |
$7K |
| D0272 |
Bitewings - two radiographic images |
799 |
579 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
57 |
38 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
32 |
14 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
43 |
27 |
$795.16 |
| D0350 |
|
14 |
14 |
$371.90 |
| D1208 |
Topical application of fluoride, excluding varnish |
40 |
31 |
$159.51 |
| D1999 |
|
1,903 |
1,671 |
$0.00 |