| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,951 |
1,951 |
$81K |
| D1206 |
Topical application of fluoride varnish |
1,921 |
1,920 |
$66K |
| D0120 |
Periodic oral evaluation - established patient |
1,506 |
1,505 |
$31K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
177 |
148 |
$19K |
| D0272 |
Bitewings - two radiographic images |
763 |
763 |
$18K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
225 |
199 |
$17K |
| D1110 |
Prophylaxis - adult |
209 |
208 |
$13K |
| D0330 |
Panoramic radiographic image |
172 |
172 |
$11K |
| D0274 |
Bitewings - four radiographic images |
279 |
279 |
$9K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
308 |
302 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
481 |
472 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
72 |
44 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
157 |
154 |
$6K |
| D0240 |
|
61 |
61 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
47 |
47 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
49 |
49 |
$826.00 |