| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
608 |
599 |
$26K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
202 |
137 |
$24K |
| D0120 |
Periodic oral evaluation - established patient |
814 |
803 |
$24K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
222 |
165 |
$21K |
| D1208 |
Topical application of fluoride, excluding varnish |
822 |
810 |
$19K |
| D1110 |
Prophylaxis - adult |
223 |
220 |
$13K |
| D1351 |
Sealant - per tooth |
262 |
95 |
$9K |
| D7140 |
Extraction, erupted tooth or exposed root |
58 |
31 |
$6K |
| D0330 |
Panoramic radiographic image |
131 |
129 |
$6K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
199 |
178 |
$4K |
| D0272 |
Bitewings - two radiographic images |
222 |
219 |
$3K |
| D0274 |
Bitewings - four radiographic images |
132 |
132 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
29 |
29 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
45 |
42 |
$405.00 |