| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
4,040 |
4,008 |
$112K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,158 |
4,126 |
$70K |
| D0120 |
Periodic oral evaluation - established patient |
4,038 |
4,007 |
$65K |
| D0240 |
|
4,107 |
2,060 |
$41K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
657 |
442 |
$32K |
| D1351 |
Sealant - per tooth |
1,251 |
417 |
$32K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,134 |
1,072 |
$29K |
| D0272 |
Bitewings - two radiographic images |
1,448 |
1,433 |
$24K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
228 |
138 |
$19K |
| D1110 |
Prophylaxis - adult |
604 |
599 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
447 |
443 |
$14K |
| D1206 |
Topical application of fluoride varnish |
340 |
338 |
$6K |
| D0330 |
Panoramic radiographic image |
139 |
139 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
88 |
50 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
110 |
110 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
240 |
239 |
$3K |
| D9630 |
|
140 |
140 |
$2K |
| D9920 |
|
38 |
38 |
$2K |
| D9310 |
|
12 |
12 |
$1K |
| D0274 |
Bitewings - four radiographic images |
104 |
104 |
$880.44 |
| D0230 |
Intraoral - periapical each additional radiographic image |
53 |
25 |
$676.29 |
| D1354 |
|
39 |
12 |
$468.00 |