| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,538 |
3,504 |
$37K |
| D1206 |
Topical application of fluoride varnish |
3,933 |
3,895 |
$27K |
| D0120 |
Periodic oral evaluation - established patient |
2,872 |
2,847 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
450 |
264 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
784 |
780 |
$4K |
| D0272 |
Bitewings - two radiographic images |
1,273 |
1,258 |
$3K |
| D0602 |
|
893 |
885 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
219 |
217 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
110 |
105 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
246 |
225 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
828 |
812 |
$858.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
551 |
465 |
$366.00 |
| D1351 |
Sealant - per tooth |
45 |
12 |
$360.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
54 |
41 |
$330.00 |
| D0240 |
|
57 |
50 |
$170.00 |
| D0274 |
Bitewings - four radiographic images |
28 |
28 |
$108.00 |
| D7140 |
Extraction, erupted tooth or exposed root |
17 |
12 |
$100.00 |
| D0601 |
|
45 |
45 |
$100.00 |
| D0603 |
|
55 |
55 |
$80.00 |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$40.00 |
| D1354 |
|
38 |
12 |
$0.00 |