| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
668 |
663 |
$29K |
| D1206 |
Topical application of fluoride varnish |
988 |
978 |
$24K |
| D0120 |
Periodic oral evaluation - established patient |
767 |
759 |
$23K |
| D1110 |
Prophylaxis - adult |
187 |
186 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
78 |
43 |
$9K |
| D0274 |
Bitewings - four radiographic images |
213 |
213 |
$5K |
| D1351 |
Sealant - per tooth |
108 |
29 |
$4K |
| D0330 |
Panoramic radiographic image |
74 |
74 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
34 |
25 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
22 |
13 |
$2K |
| D1330 |
|
399 |
395 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
43 |
43 |
$2K |
| D0272 |
Bitewings - two radiographic images |
92 |
92 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
13 |
12 |
$567.12 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
15 |
13 |
$295.35 |
| D0220 |
Intraoral - periapical first radiographic image |
28 |
27 |
$265.95 |