| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,998 |
2,510 |
$76K |
| D1351 |
Sealant - per tooth |
2,298 |
329 |
$58K |
| D0140 |
Limited oral evaluation - problem focused |
1,779 |
1,385 |
$57K |
| D0330 |
Panoramic radiographic image |
1,304 |
1,136 |
$52K |
| D0274 |
Bitewings - four radiographic images |
1,956 |
1,650 |
$44K |
| D0120 |
Periodic oral evaluation - established patient |
1,742 |
1,560 |
$44K |
| D1206 |
Topical application of fluoride varnish |
1,845 |
1,508 |
$37K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,159 |
886 |
$35K |
| D0220 |
Intraoral - periapical first radiographic image |
1,764 |
1,438 |
$21K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
169 |
81 |
$17K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,667 |
616 |
$16K |
| D1208 |
Topical application of fluoride, excluding varnish |
899 |
812 |
$14K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
47 |
25 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
90 |
24 |
$5K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
191 |
141 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
19 |
12 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
25 |
25 |
$2K |
| D0272 |
Bitewings - two radiographic images |
19 |
18 |
$163.47 |