| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,000 |
3,000 |
$126K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,827 |
2,827 |
$76K |
| D0120 |
Periodic oral evaluation - established patient |
2,608 |
2,607 |
$75K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
686 |
571 |
$63K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
528 |
429 |
$41K |
| D1351 |
Sealant - per tooth |
318 |
251 |
$39K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
427 |
400 |
$26K |
| D7140 |
Extraction, erupted tooth or exposed root |
313 |
288 |
$23K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
205 |
169 |
$22K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
480 |
479 |
$12K |
| D0272 |
Bitewings - two radiographic images |
1,019 |
1,019 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
1,627 |
1,622 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,497 |
1,496 |
$7K |
| D0274 |
Bitewings - four radiographic images |
312 |
312 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
51 |
51 |
$916.44 |
| D1206 |
Topical application of fluoride varnish |
26 |
26 |
$624.00 |