| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,155 |
1,130 |
$53K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,353 |
1,331 |
$34K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,003 |
983 |
$14K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
155 |
146 |
$5K |
| D0272 |
Bitewings - two radiographic images |
302 |
294 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
71 |
49 |
$5K |
| D1351 |
Sealant - per tooth |
243 |
85 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
91 |
30 |
$4K |
| D1206 |
Topical application of fluoride varnish |
283 |
280 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
63 |
42 |
$4K |
| D1110 |
Prophylaxis - adult |
76 |
76 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
69 |
68 |
$2K |
| D0274 |
Bitewings - four radiographic images |
49 |
49 |
$1K |
| D0330 |
Panoramic radiographic image |
32 |
31 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
44 |
44 |
$438.88 |