| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
960 |
957 |
$58K |
| D0120 |
Periodic oral evaluation - established patient |
987 |
979 |
$27K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,035 |
1,027 |
$19K |
| D0330 |
Panoramic radiographic image |
168 |
168 |
$12K |
| D1110 |
Prophylaxis - adult |
199 |
193 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
164 |
116 |
$11K |
| D0272 |
Bitewings - two radiographic images |
352 |
351 |
$8K |
| D1351 |
Sealant - per tooth |
300 |
88 |
$7K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
209 |
200 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
199 |
199 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
118 |
86 |
$6K |
| D0274 |
Bitewings - four radiographic images |
114 |
114 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
49 |
37 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
81 |
76 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
259 |
248 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
217 |
158 |
$2K |
| D1206 |
Topical application of fluoride varnish |
113 |
113 |
$2K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
16 |
13 |
$2K |