| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,651 |
3,651 |
$127K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,163 |
711 |
$111K |
| D0120 |
Periodic oral evaluation - established patient |
3,840 |
3,840 |
$89K |
| D1206 |
Topical application of fluoride varnish |
4,867 |
4,867 |
$79K |
| D1110 |
Prophylaxis - adult |
1,433 |
1,433 |
$69K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,805 |
1,653 |
$55K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
731 |
529 |
$52K |
| D0272 |
Bitewings - two radiographic images |
2,159 |
2,159 |
$41K |
| D1351 |
Sealant - per tooth |
1,382 |
493 |
$39K |
| D0274 |
Bitewings - four radiographic images |
974 |
974 |
$26K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
572 |
572 |
$23K |
| D7140 |
Extraction, erupted tooth or exposed root |
281 |
169 |
$23K |
| D0330 |
Panoramic radiographic image |
359 |
359 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
1,238 |
1,229 |
$16K |
| D9248 |
|
190 |
169 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
836 |
739 |
$9K |
| D0240 |
|
426 |
235 |
$7K |
| D0145 |
Oral evaluation for a patient under three years of age |
95 |
95 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
158 |
158 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$458.60 |