| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,655 |
2,314 |
$107K |
| D1351 |
Sealant - per tooth |
1,109 |
571 |
$84K |
| D1206 |
Topical application of fluoride varnish |
2,421 |
2,129 |
$62K |
| D0120 |
Periodic oral evaluation - established patient |
2,162 |
1,893 |
$60K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
381 |
301 |
$29K |
| D0274 |
Bitewings - four radiographic images |
883 |
775 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
2,443 |
2,114 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,266 |
1,963 |
$13K |
| D7140 |
Extraction, erupted tooth or exposed root |
184 |
140 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
440 |
358 |
$9K |
| D0210 |
Intraoral - complete series of radiographic images |
419 |
289 |
$7K |
| D0272 |
Bitewings - two radiographic images |
351 |
307 |
$3K |
| D0330 |
Panoramic radiographic image |
153 |
114 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
23 |
15 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
32 |
29 |
$832.00 |