| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,779 |
2,759 |
$106K |
| D0120 |
Periodic oral evaluation - established patient |
1,804 |
1,803 |
$90K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,753 |
2,733 |
$41K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,371 |
1,602 |
$21K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
431 |
409 |
$17K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
247 |
245 |
$16K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
192 |
121 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
974 |
956 |
$11K |
| D7140 |
Extraction, erupted tooth or exposed root |
87 |
52 |
$5K |
| D0145 |
Oral evaluation for a patient under three years of age |
96 |
96 |
$5K |
| D0272 |
Bitewings - two radiographic images |
213 |
213 |
$2K |
| D0274 |
Bitewings - four radiographic images |
50 |
50 |
$1K |
| D1351 |
Sealant - per tooth |
45 |
12 |
$968.00 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
12 |
12 |
$957.60 |