| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,688 |
1,686 |
$96K |
| D0120 |
Periodic oral evaluation - established patient |
1,459 |
1,456 |
$39K |
| D1206 |
Topical application of fluoride varnish |
1,666 |
1,664 |
$30K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
359 |
261 |
$25K |
| D0330 |
Panoramic radiographic image |
346 |
345 |
$22K |
| D0272 |
Bitewings - two radiographic images |
869 |
868 |
$18K |
| D1110 |
Prophylaxis - adult |
287 |
287 |
$17K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
553 |
553 |
$16K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
516 |
504 |
$15K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
265 |
213 |
$15K |
| D1208 |
Topical application of fluoride, excluding varnish |
319 |
319 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
64 |
40 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
250 |
248 |
$3K |
| D0274 |
Bitewings - four radiographic images |
37 |
37 |
$1K |
| D1351 |
Sealant - per tooth |
29 |
15 |
$553.80 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$513.15 |