| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,274 |
1,180 |
$50K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
588 |
412 |
$34K |
| D0120 |
Periodic oral evaluation - established patient |
995 |
910 |
$27K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
865 |
799 |
$18K |
| D1208 |
Topical application of fluoride, excluding varnish |
527 |
462 |
$13K |
| D1206 |
Topical application of fluoride varnish |
478 |
461 |
$12K |
| D1351 |
Sealant - per tooth |
152 |
86 |
$10K |
| D0274 |
Bitewings - four radiographic images |
581 |
530 |
$9K |
| D1110 |
Prophylaxis - adult |
225 |
200 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
1,435 |
1,313 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
196 |
149 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,156 |
1,031 |
$6K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
179 |
145 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
289 |
262 |
$4K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
29 |
26 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
38 |
30 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
92 |
85 |
$1K |
| D0272 |
Bitewings - two radiographic images |
108 |
104 |
$947.50 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
17 |
12 |
$907.85 |
| D0330 |
Panoramic radiographic image |
38 |
38 |
$568.80 |