| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
11,770 |
7,214 |
$199K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,090 |
908 |
$186K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
4,657 |
3,702 |
$154K |
| D1351 |
Sealant - per tooth |
6,748 |
908 |
$133K |
| D1206 |
Topical application of fluoride varnish |
6,833 |
4,850 |
$117K |
| D0330 |
Panoramic radiographic image |
2,023 |
1,610 |
$72K |
| D0120 |
Periodic oral evaluation - established patient |
6,557 |
2,983 |
$63K |
| D0272 |
Bitewings - two radiographic images |
6,030 |
3,363 |
$57K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,907 |
1,461 |
$54K |
| D7140 |
Extraction, erupted tooth or exposed root |
665 |
369 |
$46K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,838 |
2,355 |
$33K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
361 |
220 |
$28K |
| D0274 |
Bitewings - four radiographic images |
1,081 |
864 |
$25K |
| D0140 |
Limited oral evaluation - problem focused |
548 |
464 |
$19K |
| D0145 |
Oral evaluation for a patient under three years of age |
607 |
490 |
$19K |
| D0210 |
Intraoral - complete series of radiographic images |
267 |
267 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
1,632 |
1,294 |
$17K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,183 |
933 |
$11K |
| D1110 |
Prophylaxis - adult |
13 |
13 |
$786.00 |
| D0603 |
|
4,555 |
3,117 |
$0.00 |