| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
754 |
753 |
$32K |
| D0120 |
Periodic oral evaluation - established patient |
818 |
818 |
$23K |
| D1351 |
Sealant - per tooth |
363 |
104 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
216 |
143 |
$14K |
| D1110 |
Prophylaxis - adult |
247 |
247 |
$14K |
| D0274 |
Bitewings - four radiographic images |
461 |
461 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
714 |
713 |
$10K |
| D1206 |
Topical application of fluoride varnish |
329 |
328 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
652 |
652 |
$9K |
| D0330 |
Panoramic radiographic image |
223 |
223 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
93 |
74 |
$5K |
| D0272 |
Bitewings - two radiographic images |
187 |
186 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
86 |
85 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
16 |
15 |
$903.00 |
| D0145 |
Oral evaluation for a patient under three years of age |
12 |
12 |
$360.00 |