| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
232 |
231 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
326 |
325 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
261 |
260 |
$5K |
| D1310 |
|
320 |
320 |
$3K |
| D1330 |
|
304 |
304 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
49 |
48 |
$2K |
| D1110 |
Prophylaxis - adult |
46 |
46 |
$2K |
| D1351 |
Sealant - per tooth |
79 |
12 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
22 |
13 |
$1K |
| D0274 |
Bitewings - four radiographic images |
68 |
68 |
$1K |
| D0272 |
Bitewings - two radiographic images |
90 |
90 |
$992.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
16 |
15 |
$960.00 |
| D0220 |
Intraoral - periapical first radiographic image |
115 |
114 |
$860.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
109 |
97 |
$752.00 |
| D0601 |
|
94 |
94 |
$0.00 |
| D0603 |
|
137 |
137 |
$0.00 |