| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
958 |
951 |
$32K |
| D1206 |
Topical application of fluoride varnish |
1,129 |
1,121 |
$23K |
| D0120 |
Periodic oral evaluation - established patient |
960 |
955 |
$19K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
210 |
202 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
105 |
51 |
$7K |
| D0272 |
Bitewings - two radiographic images |
346 |
345 |
$7K |
| D1110 |
Prophylaxis - adult |
154 |
153 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
70 |
43 |
$6K |
| D9248 |
|
53 |
52 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
134 |
133 |
$4K |
| D1351 |
Sealant - per tooth |
114 |
38 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
59 |
58 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
19 |
17 |
$1K |
| D0240 |
|
94 |
54 |
$1K |
| D9630 |
|
49 |
49 |
$973.63 |
| D0274 |
Bitewings - four radiographic images |
29 |
29 |
$772.80 |
| D0220 |
Intraoral - periapical first radiographic image |
27 |
26 |
$301.86 |