| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
397 |
395 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
414 |
412 |
$11K |
| D1206 |
Topical application of fluoride varnish |
520 |
518 |
$11K |
| D1351 |
Sealant - per tooth |
338 |
71 |
$10K |
| D1354 |
|
174 |
52 |
$10K |
| D1110 |
Prophylaxis - adult |
144 |
144 |
$9K |
| D7140 |
Extraction, erupted tooth or exposed root |
78 |
42 |
$5K |
| D0330 |
Panoramic radiographic image |
74 |
74 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
58 |
38 |
$5K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
87 |
81 |
$4K |
| D0274 |
Bitewings - four radiographic images |
79 |
79 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
289 |
95 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
190 |
186 |
$3K |
| D0272 |
Bitewings - two radiographic images |
105 |
105 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
59 |
59 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
20 |
13 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
44 |
44 |
$2K |
| D9310 |
|
13 |
13 |
$715.00 |