| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
306 |
290 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
336 |
321 |
$9K |
| D1351 |
Sealant - per tooth |
175 |
58 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
302 |
286 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
62 |
48 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
479 |
453 |
$3K |
| D0274 |
Bitewings - four radiographic images |
193 |
188 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
446 |
395 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
35 |
35 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
79 |
77 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
34 |
29 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
17 |
12 |
$969.36 |
| D0272 |
Bitewings - two radiographic images |
101 |
100 |
$708.07 |
| D0140 |
Limited oral evaluation - problem focused |
38 |
37 |
$707.44 |
| D1110 |
Prophylaxis - adult |
15 |
15 |
$677.32 |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$319.71 |