| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
882 |
799 |
$33K |
| D1206 |
Topical application of fluoride varnish |
340 |
334 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
776 |
712 |
$11K |
| D1351 |
Sealant - per tooth |
475 |
119 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
226 |
95 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
247 |
244 |
$8K |
| D0272 |
Bitewings - two radiographic images |
485 |
433 |
$7K |
| D9248 |
|
69 |
56 |
$5K |
| D0330 |
Panoramic radiographic image |
142 |
125 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
556 |
476 |
$4K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
327 |
260 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
95 |
91 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
192 |
163 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
52 |
24 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
20 |
13 |
$709.45 |
| D9215 |
|
232 |
209 |
$362.85 |
| D0230 |
Intraoral - periapical each additional radiographic image |
32 |
32 |
$182.59 |