| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
576 |
563 |
$48K |
| D0120 |
Periodic oral evaluation - established patient |
1,455 |
1,400 |
$40K |
| D1120 |
Prophylaxis - child |
1,065 |
1,010 |
$29K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
389 |
287 |
$29K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
180 |
165 |
$14K |
| D7140 |
Extraction, erupted tooth or exposed root |
147 |
100 |
$8K |
| D0330 |
Panoramic radiographic image |
130 |
117 |
$6K |
| D1351 |
Sealant - per tooth |
575 |
200 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
51 |
42 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
134 |
124 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
207 |
181 |
$752.41 |
| D0272 |
Bitewings - two radiographic images |
890 |
841 |
$546.47 |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,228 |
1,171 |
$252.04 |
| D0220 |
Intraoral - periapical first radiographic image |
1,319 |
1,264 |
$130.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
980 |
918 |
$126.50 |
| D1330 |
|
1,679 |
1,610 |
$103.83 |
| D0240 |
|
295 |
280 |
$20.00 |
| D0274 |
Bitewings - four radiographic images |
564 |
551 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
623 |
622 |
$0.00 |
| D3120 |
|
17 |
14 |
$0.00 |