| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,672 |
1,672 |
$51K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
927 |
569 |
$49K |
| D0120 |
Periodic oral evaluation - established patient |
2,040 |
2,040 |
$42K |
| D1351 |
Sealant - per tooth |
934 |
307 |
$30K |
| D0274 |
Bitewings - four radiographic images |
1,447 |
1,447 |
$30K |
| D1206 |
Topical application of fluoride varnish |
827 |
827 |
$18K |
| D1110 |
Prophylaxis - adult |
432 |
432 |
$18K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,759 |
1,757 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
1,738 |
1,735 |
$17K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,307 |
1,307 |
$14K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
315 |
223 |
$11K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
59 |
45 |
$4K |
| D1320 |
|
420 |
420 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
36 |
25 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
47 |
40 |
$1K |
| D9920 |
|
33 |
28 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
16 |
16 |
$320.88 |