| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
631 |
630 |
$20K |
| D1208 |
Topical application of fluoride, excluding varnish |
856 |
855 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
434 |
433 |
$15K |
| D0274 |
Bitewings - four radiographic images |
352 |
352 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
817 |
813 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
374 |
374 |
$8K |
| D1110 |
Prophylaxis - adult |
175 |
175 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
777 |
776 |
$7K |
| D0272 |
Bitewings - two radiographic images |
335 |
334 |
$7K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
216 |
197 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
45 |
26 |
$3K |
| D1351 |
Sealant - per tooth |
93 |
30 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
35 |
20 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
21 |
17 |
$2K |