| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,333 |
1,295 |
$55K |
| D0120 |
Periodic oral evaluation - established patient |
1,684 |
1,640 |
$53K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
370 |
292 |
$53K |
| D1206 |
Topical application of fluoride varnish |
1,995 |
1,949 |
$52K |
| D1110 |
Prophylaxis - adult |
739 |
730 |
$40K |
| D0330 |
Panoramic radiographic image |
437 |
430 |
$29K |
| D0272 |
Bitewings - two radiographic images |
741 |
725 |
$21K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
297 |
291 |
$16K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
131 |
94 |
$14K |
| D0274 |
Bitewings - four radiographic images |
358 |
353 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
379 |
371 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
17 |
13 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
44 |
29 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
103 |
89 |
$3K |
| D1351 |
Sealant - per tooth |
87 |
16 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
13 |
13 |
$389.00 |