| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
4,991 |
4,902 |
$33K |
| D0120 |
Periodic oral evaluation - established patient |
4,901 |
4,825 |
$21K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,163 |
437 |
$16K |
| D0272 |
Bitewings - two radiographic images |
3,488 |
3,415 |
$13K |
| D1206 |
Topical application of fluoride varnish |
2,079 |
2,075 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,306 |
3,218 |
$8K |
| D1351 |
Sealant - per tooth |
1,536 |
428 |
$6K |
| D0274 |
Bitewings - four radiographic images |
964 |
943 |
$4K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
600 |
571 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
138 |
69 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
958 |
911 |
$2K |
| D0240 |
|
707 |
320 |
$2K |
| D1110 |
Prophylaxis - adult |
230 |
226 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
220 |
206 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
21 |
12 |
$800.80 |
| D0140 |
Limited oral evaluation - problem focused |
183 |
167 |
$728.79 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
23 |
12 |
$343.83 |
| D0230 |
Intraoral - periapical each additional radiographic image |
67 |
40 |
$104.58 |
| D1354 |
|
153 |
45 |
$36.76 |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$0.00 |