| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,505 |
3,454 |
$150K |
| D0120 |
Periodic oral evaluation - established patient |
3,340 |
3,290 |
$98K |
| D1206 |
Topical application of fluoride varnish |
3,426 |
3,379 |
$84K |
| D1351 |
Sealant - per tooth |
1,191 |
215 |
$39K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
640 |
634 |
$34K |
| D0272 |
Bitewings - two radiographic images |
2,160 |
2,129 |
$33K |
| D1208 |
Topical application of fluoride, excluding varnish |
956 |
940 |
$22K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
153 |
102 |
$19K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
947 |
887 |
$17K |
| D7140 |
Extraction, erupted tooth or exposed root |
118 |
75 |
$12K |
| D0330 |
Panoramic radiographic image |
205 |
203 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
70 |
52 |
$7K |
| D1110 |
Prophylaxis - adult |
114 |
112 |
$7K |
| D0274 |
Bitewings - four radiographic images |
232 |
229 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
156 |
155 |
$1K |
| D0240 |
|
16 |
16 |
$180.00 |