| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,105 |
1,096 |
$31K |
| D0120 |
Periodic oral evaluation - established patient |
1,219 |
1,211 |
$24K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
264 |
135 |
$24K |
| D1110 |
Prophylaxis - adult |
384 |
384 |
$15K |
| D1206 |
Topical application of fluoride varnish |
561 |
558 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
255 |
255 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
735 |
731 |
$8K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
287 |
261 |
$7K |
| D0272 |
Bitewings - two radiographic images |
376 |
372 |
$7K |
| D0240 |
|
143 |
117 |
$4K |
| D0274 |
Bitewings - four radiographic images |
136 |
136 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
47 |
44 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
88 |
80 |
$736.57 |
| D0330 |
Panoramic radiographic image |
14 |
14 |
$735.70 |
| D7140 |
Extraction, erupted tooth or exposed root |
31 |
14 |
$95.00 |