| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
403 |
403 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
514 |
514 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
552 |
552 |
$8K |
| D0330 |
Panoramic radiographic image |
125 |
125 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
64 |
32 |
$5K |
| D1110 |
Prophylaxis - adult |
120 |
120 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
60 |
33 |
$4K |
| D0274 |
Bitewings - four radiographic images |
105 |
105 |
$3K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
24 |
12 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
106 |
103 |
$3K |
| D0272 |
Bitewings - two radiographic images |
145 |
145 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
85 |
84 |
$2K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
17 |
13 |
$2K |
| D7111 |
|
32 |
24 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
122 |
120 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
27 |
14 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
17 |
17 |
$479.40 |
| D0230 |
Intraoral - periapical each additional radiographic image |
24 |
21 |
$169.20 |