| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
959 |
867 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,144 |
1,043 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
344 |
172 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
911 |
835 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
386 |
327 |
$773.75 |
| D0272 |
Bitewings - two radiographic images |
424 |
369 |
$694.68 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
255 |
225 |
$568.00 |
| D0140 |
Limited oral evaluation - problem focused |
93 |
80 |
$370.80 |
| D7140 |
Extraction, erupted tooth or exposed root |
27 |
13 |
$301.24 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
141 |
81 |
$222.00 |
| D1110 |
Prophylaxis - adult |
169 |
156 |
$143.25 |
| D0330 |
Panoramic radiographic image |
35 |
29 |
$129.04 |
| D0220 |
Intraoral - periapical first radiographic image |
133 |
122 |
$106.00 |
| D0210 |
Intraoral - complete series of radiographic images |
82 |
78 |
$72.25 |
| D1351 |
Sealant - per tooth |
544 |
83 |
$58.70 |
| D0230 |
Intraoral - periapical each additional radiographic image |
57 |
28 |
$50.00 |