| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,190 |
2,190 |
$88K |
| D0120 |
Periodic oral evaluation - established patient |
2,401 |
2,399 |
$65K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
423 |
419 |
$59K |
| D1206 |
Topical application of fluoride varnish |
1,204 |
1,204 |
$33K |
| D0272 |
Bitewings - two radiographic images |
1,456 |
1,456 |
$30K |
| D1351 |
Sealant - per tooth |
780 |
230 |
$29K |
| D1110 |
Prophylaxis - adult |
550 |
549 |
$29K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
357 |
211 |
$27K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,723 |
1,722 |
$23K |
| D0330 |
Panoramic radiographic image |
354 |
354 |
$16K |
| D0274 |
Bitewings - four radiographic images |
419 |
419 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
158 |
158 |
$5K |
| D1354 |
|
122 |
41 |
$4K |
| D0145 |
Oral evaluation for a patient under three years of age |
136 |
136 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
137 |
136 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
75 |
75 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
24 |
12 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
64 |
56 |
$759.50 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
16 |
12 |
$691.43 |