| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,815 |
1,806 |
$80K |
| D1206 |
Topical application of fluoride varnish |
1,852 |
1,844 |
$57K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
492 |
314 |
$43K |
| D0120 |
Periodic oral evaluation - established patient |
1,290 |
1,284 |
$32K |
| D1351 |
Sealant - per tooth |
1,064 |
179 |
$26K |
| D0274 |
Bitewings - four radiographic images |
484 |
482 |
$16K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
647 |
601 |
$16K |
| D0272 |
Bitewings - two radiographic images |
768 |
765 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
859 |
849 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
114 |
89 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
737 |
730 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
114 |
114 |
$5K |
| D0603 |
|
394 |
393 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
40 |
25 |
$3K |
| D0602 |
|
271 |
268 |
$3K |
| D1354 |
|
257 |
109 |
$2K |
| D0273 |
|
46 |
46 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$490.00 |
| D0240 |
|
23 |
23 |
$450.00 |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$330.00 |
| D0601 |
|
12 |
12 |
$120.00 |