| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,097 |
2,097 |
$90K |
| D0120 |
Periodic oral evaluation - established patient |
2,385 |
2,383 |
$69K |
| D7140 |
Extraction, erupted tooth or exposed root |
420 |
311 |
$37K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
492 |
418 |
$36K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,264 |
1,264 |
$34K |
| D1110 |
Prophylaxis - adult |
471 |
471 |
$23K |
| D0274 |
Bitewings - four radiographic images |
936 |
935 |
$19K |
| D1206 |
Topical application of fluoride varnish |
667 |
667 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
614 |
614 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
2,134 |
2,105 |
$14K |
| D4341 |
|
70 |
38 |
$12K |
| D0140 |
Limited oral evaluation - problem focused |
605 |
586 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
253 |
228 |
$11K |
| D0210 |
Intraoral - complete series of radiographic images |
290 |
290 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,628 |
1,624 |
$10K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
80 |
69 |
$8K |
| D1351 |
Sealant - per tooth |
38 |
32 |
$5K |
| D0272 |
Bitewings - two radiographic images |
423 |
423 |
$5K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
12 |
12 |
$840.00 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$284.49 |