| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,094 |
2,069 |
$115K |
| D1110 |
Prophylaxis - adult |
700 |
695 |
$38K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,243 |
1,227 |
$36K |
| D0120 |
Periodic oral evaluation - established patient |
1,665 |
1,652 |
$35K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
434 |
311 |
$29K |
| D0330 |
Panoramic radiographic image |
669 |
663 |
$27K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
510 |
354 |
$23K |
| D1206 |
Topical application of fluoride varnish |
1,526 |
1,521 |
$23K |
| D0274 |
Bitewings - four radiographic images |
739 |
732 |
$22K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,397 |
1,372 |
$21K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
378 |
340 |
$13K |
| D0272 |
Bitewings - two radiographic images |
663 |
657 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
394 |
390 |
$4K |
| D1351 |
Sealant - per tooth |
148 |
54 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
334 |
106 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
31 |
20 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
41 |
39 |
$1K |