| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,294 |
2,250 |
$102K |
| D0272 |
Bitewings - two radiographic images |
2,340 |
2,301 |
$88K |
| D0120 |
Periodic oral evaluation - established patient |
2,679 |
2,627 |
$88K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,978 |
2,914 |
$72K |
| D1110 |
Prophylaxis - adult |
697 |
675 |
$50K |
| D7140 |
Extraction, erupted tooth or exposed root |
237 |
135 |
$25K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
118 |
78 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
171 |
163 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
391 |
383 |
$7K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
81 |
79 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
13 |
12 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
26 |
15 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
28 |
28 |
$1K |
| D1206 |
Topical application of fluoride varnish |
25 |
25 |
$725.00 |
| D0274 |
Bitewings - four radiographic images |
14 |
14 |
$604.80 |