| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,686 |
2,681 |
$148K |
| D1110 |
Prophylaxis - adult |
855 |
855 |
$62K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
359 |
211 |
$25K |
| D1351 |
Sealant - per tooth |
1,482 |
418 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
3,793 |
3,787 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
41 |
25 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
18 |
13 |
$971.27 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
472 |
445 |
$173.90 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$171.83 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
14 |
14 |
$37.12 |
| D0220 |
Intraoral - periapical first radiographic image |
101 |
100 |
$27.66 |
| D0272 |
Bitewings - two radiographic images |
1,660 |
1,659 |
$15.87 |
| D0274 |
Bitewings - four radiographic images |
204 |
204 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
1,259 |
1,256 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
2,263 |
2,258 |
$-205.61 |