| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,634 |
2,633 |
$113K |
| D0120 |
Periodic oral evaluation - established patient |
2,354 |
2,354 |
$64K |
| D1206 |
Topical application of fluoride varnish |
1,276 |
1,276 |
$38K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
300 |
135 |
$24K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,106 |
1,106 |
$16K |
| D0272 |
Bitewings - two radiographic images |
701 |
701 |
$11K |
| D1110 |
Prophylaxis - adult |
152 |
152 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
174 |
78 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
193 |
193 |
$6K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
187 |
185 |
$6K |
| D0145 |
Oral evaluation for a patient under three years of age |
178 |
178 |
$5K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
44 |
12 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
68 |
41 |
$3K |
| D0240 |
|
109 |
105 |
$3K |
| D1351 |
Sealant - per tooth |
37 |
12 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
38 |
38 |
$537.90 |
| D0220 |
Intraoral - periapical first radiographic image |
38 |
37 |
$507.50 |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$499.20 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$327.12 |