| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,187 |
1,166 |
$48K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,077 |
1,057 |
$24K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
478 |
464 |
$22K |
| D0120 |
Periodic oral evaluation - established patient |
763 |
758 |
$21K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
90 |
57 |
$10K |
| D9920 |
|
133 |
129 |
$9K |
| D1206 |
Topical application of fluoride varnish |
323 |
323 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
60 |
45 |
$5K |
| D0272 |
Bitewings - two radiographic images |
239 |
239 |
$4K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
110 |
109 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
106 |
86 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
66 |
59 |
$3K |
| D1330 |
|
446 |
425 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
168 |
166 |
$2K |
| D1110 |
Prophylaxis - adult |
40 |
40 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
167 |
69 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
24 |
16 |
$2K |
| D0274 |
Bitewings - four radiographic images |
50 |
50 |
$1K |
| D0240 |
|
74 |
41 |
$941.05 |
| D1351 |
Sealant - per tooth |
27 |
12 |
$760.00 |