| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,359 |
1,204 |
$49K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
653 |
492 |
$35K |
| D0120 |
Periodic oral evaluation - established patient |
1,254 |
1,093 |
$30K |
| D1206 |
Topical application of fluoride varnish |
693 |
581 |
$16K |
| D1208 |
Topical application of fluoride, excluding varnish |
550 |
527 |
$13K |
| D7140 |
Extraction, erupted tooth or exposed root |
213 |
104 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
277 |
221 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
437 |
403 |
$8K |
| D0274 |
Bitewings - four radiographic images |
573 |
498 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
302 |
273 |
$4K |
| D1110 |
Prophylaxis - adult |
94 |
82 |
$3K |
| D1351 |
Sealant - per tooth |
26 |
13 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
353 |
305 |
$2K |
| D2950 |
|
31 |
26 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
59 |
56 |
$1K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
12 |
12 |
$686.70 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
14 |
12 |
$364.00 |
| D0330 |
Panoramic radiographic image |
16 |
14 |
$248.60 |