| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
913 |
867 |
$23K |
| D0120 |
Periodic oral evaluation - established patient |
990 |
941 |
$19K |
| D1206 |
Topical application of fluoride varnish |
1,209 |
1,159 |
$18K |
| D1351 |
Sealant - per tooth |
627 |
121 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
159 |
104 |
$11K |
| D0272 |
Bitewings - two radiographic images |
532 |
499 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
131 |
99 |
$8K |
| D1110 |
Prophylaxis - adult |
211 |
200 |
$7K |
| D0274 |
Bitewings - four radiographic images |
271 |
260 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
724 |
270 |
$7K |
| D0330 |
Panoramic radiographic image |
225 |
212 |
$7K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
301 |
277 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
198 |
188 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
423 |
393 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
28 |
15 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
37 |
34 |
$909.85 |