| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
4,903 |
4,828 |
$173K |
| D1206 |
Topical application of fluoride varnish |
6,462 |
6,356 |
$128K |
| D0120 |
Periodic oral evaluation - established patient |
5,015 |
4,927 |
$124K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
717 |
412 |
$89K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,147 |
1,133 |
$46K |
| D1110 |
Prophylaxis - adult |
795 |
772 |
$40K |
| D0272 |
Bitewings - two radiographic images |
1,891 |
1,861 |
$40K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
991 |
938 |
$31K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
215 |
142 |
$21K |
| D0240 |
|
500 |
498 |
$18K |
| D0330 |
Panoramic radiographic image |
292 |
279 |
$16K |
| D1351 |
Sealant - per tooth |
387 |
138 |
$13K |
| D0274 |
Bitewings - four radiographic images |
163 |
163 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
22 |
13 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
50 |
50 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
28 |
28 |
$357.39 |