| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
463 |
438 |
$19K |
| D1206 |
Topical application of fluoride varnish |
523 |
496 |
$18K |
| D0120 |
Periodic oral evaluation - established patient |
575 |
545 |
$14K |
| D1351 |
Sealant - per tooth |
545 |
108 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
170 |
84 |
$8K |
| D9248 |
|
65 |
61 |
$6K |
| D1110 |
Prophylaxis - adult |
89 |
89 |
$4K |
| D0272 |
Bitewings - two radiographic images |
219 |
214 |
$4K |
| D0330 |
Panoramic radiographic image |
101 |
99 |
$4K |
| D0274 |
Bitewings - four radiographic images |
124 |
124 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
71 |
41 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
48 |
47 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
34 |
25 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
141 |
129 |
$1K |
| D0240 |
|
51 |
26 |
$727.65 |
| D0220 |
Intraoral - periapical first radiographic image |
61 |
55 |
$632.70 |
| D0230 |
Intraoral - periapical each additional radiographic image |
47 |
31 |
$482.82 |
| D1208 |
Topical application of fluoride, excluding varnish |
42 |
38 |
$358.40 |
| D1999 |
|
19 |
16 |
$0.00 |
| D0350 |
|
18 |
15 |
$0.00 |