| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
678 |
678 |
$41K |
| D0120 |
Periodic oral evaluation - established patient |
680 |
680 |
$19K |
| D1208 |
Topical application of fluoride, excluding varnish |
800 |
800 |
$15K |
| D0330 |
Panoramic radiographic image |
166 |
166 |
$12K |
| D1110 |
Prophylaxis - adult |
146 |
146 |
$9K |
| D0272 |
Bitewings - two radiographic images |
282 |
282 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
165 |
165 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
57 |
43 |
$4K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
102 |
100 |
$4K |
| D1351 |
Sealant - per tooth |
140 |
34 |
$3K |
| D0274 |
Bitewings - four radiographic images |
73 |
73 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
41 |
37 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
177 |
172 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
154 |
115 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
17 |
12 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
29 |
28 |
$1K |