| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
912 |
901 |
$35K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
483 |
299 |
$31K |
| D1351 |
Sealant - per tooth |
508 |
228 |
$27K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,132 |
1,114 |
$23K |
| D1206 |
Topical application of fluoride varnish |
855 |
844 |
$20K |
| D1110 |
Prophylaxis - adult |
464 |
445 |
$18K |
| D0120 |
Periodic oral evaluation - established patient |
639 |
624 |
$17K |
| D7140 |
Extraction, erupted tooth or exposed root |
276 |
95 |
$13K |
| D0274 |
Bitewings - four radiographic images |
796 |
780 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,043 |
1,533 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
212 |
174 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
1,758 |
1,703 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
181 |
134 |
$7K |
| D0330 |
Panoramic radiographic image |
251 |
247 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
271 |
261 |
$4K |
| D0272 |
Bitewings - two radiographic images |
280 |
277 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
36 |
29 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
14 |
13 |
$364.00 |
| D0210 |
Intraoral - complete series of radiographic images |
69 |
65 |
$353.30 |