| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,928 |
3,794 |
$164K |
| D1206 |
Topical application of fluoride varnish |
4,273 |
4,123 |
$147K |
| D0120 |
Periodic oral evaluation - established patient |
4,079 |
3,936 |
$83K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
418 |
299 |
$44K |
| D0272 |
Bitewings - two radiographic images |
1,244 |
1,206 |
$30K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
895 |
839 |
$26K |
| D1110 |
Prophylaxis - adult |
402 |
383 |
$24K |
| D1351 |
Sealant - per tooth |
729 |
248 |
$24K |
| D0274 |
Bitewings - four radiographic images |
605 |
574 |
$21K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
266 |
188 |
$20K |
| D7140 |
Extraction, erupted tooth or exposed root |
205 |
103 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
897 |
852 |
$13K |
| D0240 |
|
242 |
227 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
428 |
403 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
131 |
131 |
$5K |
| D9920 |
|
149 |
136 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
102 |
101 |
$3K |
| D0330 |
Panoramic radiographic image |
25 |
25 |
$2K |
| D1354 |
|
21 |
13 |
$510.00 |
| D0145 |
Oral evaluation for a patient under three years of age |
12 |
12 |
$357.00 |