| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
686 |
617 |
$23K |
| D0120 |
Periodic oral evaluation - established patient |
769 |
691 |
$18K |
| D1208 |
Topical application of fluoride, excluding varnish |
690 |
621 |
$14K |
| D1351 |
Sealant - per tooth |
266 |
137 |
$12K |
| D1110 |
Prophylaxis - adult |
195 |
176 |
$7K |
| D0274 |
Bitewings - four radiographic images |
357 |
319 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
93 |
64 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
259 |
234 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
110 |
73 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
47 |
29 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
394 |
353 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
344 |
261 |
$1K |
| D0272 |
Bitewings - two radiographic images |
166 |
148 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
43 |
38 |
$832.00 |