| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
400 |
396 |
$20K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
131 |
98 |
$19K |
| D0120 |
Periodic oral evaluation - established patient |
484 |
480 |
$19K |
| D1206 |
Topical application of fluoride varnish |
596 |
592 |
$18K |
| D0272 |
Bitewings - two radiographic images |
360 |
356 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
58 |
42 |
$9K |
| D0274 |
Bitewings - four radiographic images |
197 |
197 |
$9K |
| D1110 |
Prophylaxis - adult |
140 |
140 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
67 |
42 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
199 |
199 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
21 |
14 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
87 |
87 |
$4K |
| D2140 |
|
20 |
18 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
100 |
69 |
$2K |
| D1351 |
Sealant - per tooth |
50 |
15 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
15 |
15 |
$999.00 |