| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
960 |
960 |
$29K |
| D1206 |
Topical application of fluoride varnish |
1,195 |
1,192 |
$21K |
| D0120 |
Periodic oral evaluation - established patient |
732 |
732 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
105 |
53 |
$6K |
| D0272 |
Bitewings - two radiographic images |
297 |
297 |
$5K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
73 |
72 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
153 |
153 |
$3K |
| D0145 |
Oral evaluation for a patient under three years of age |
133 |
133 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
250 |
249 |
$2K |
| D1351 |
Sealant - per tooth |
65 |
14 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
189 |
159 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
17 |
12 |
$1K |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$432.00 |