| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
452 |
226 |
$20K |
| D1206 |
Topical application of fluoride varnish |
540 |
270 |
$19K |
| D0120 |
Periodic oral evaluation - established patient |
492 |
246 |
$12K |
| D7140 |
Extraction, erupted tooth or exposed root |
74 |
19 |
$6K |
| D1110 |
Prophylaxis - adult |
102 |
51 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
76 |
28 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
48 |
19 |
$5K |
| D1351 |
Sealant - per tooth |
136 |
22 |
$4K |
| D0272 |
Bitewings - two radiographic images |
164 |
82 |
$4K |
| D0274 |
Bitewings - four radiographic images |
106 |
53 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
42 |
21 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
32 |
16 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
69 |
35 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
28 |
14 |
$980.00 |