| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,522 |
2,835 |
$81K |
| D0330 |
Panoramic radiographic image |
1,549 |
1,251 |
$60K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,039 |
1,620 |
$55K |
| D0140 |
Limited oral evaluation - problem focused |
1,610 |
1,255 |
$50K |
| D1206 |
Topical application of fluoride varnish |
2,292 |
1,814 |
$43K |
| D0120 |
Periodic oral evaluation - established patient |
1,510 |
1,251 |
$34K |
| D0274 |
Bitewings - four radiographic images |
1,603 |
1,204 |
$33K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
313 |
211 |
$30K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
248 |
119 |
$17K |
| D1351 |
Sealant - per tooth |
384 |
74 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
501 |
420 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
87 |
45 |
$5K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
97 |
76 |
$950.40 |
| D0220 |
Intraoral - periapical first radiographic image |
74 |
55 |
$663.94 |