| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,029 |
881 |
$54K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
458 |
263 |
$27K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,172 |
986 |
$19K |
| D0120 |
Periodic oral evaluation - established patient |
768 |
665 |
$18K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
415 |
340 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
530 |
432 |
$14K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
124 |
96 |
$10K |
| D0330 |
Panoramic radiographic image |
218 |
191 |
$9K |
| D1110 |
Prophylaxis - adult |
152 |
120 |
$8K |
| D0272 |
Bitewings - two radiographic images |
302 |
250 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
96 |
50 |
$5K |
| D0274 |
Bitewings - four radiographic images |
120 |
93 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
260 |
218 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
78 |
38 |
$3K |
| D1351 |
Sealant - per tooth |
118 |
39 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
34 |
27 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
71 |
56 |
$665.51 |