| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
822 |
822 |
$29K |
| D0120 |
Periodic oral evaluation - established patient |
929 |
929 |
$21K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
197 |
140 |
$20K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
614 |
558 |
$19K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,184 |
1,184 |
$19K |
| D1110 |
Prophylaxis - adult |
381 |
381 |
$18K |
| D1351 |
Sealant - per tooth |
458 |
159 |
$13K |
| D0272 |
Bitewings - two radiographic images |
624 |
624 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
114 |
78 |
$8K |
| D0274 |
Bitewings - four radiographic images |
237 |
237 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
135 |
135 |
$5K |
| D9248 |
|
45 |
40 |
$3K |
| D0240 |
|
152 |
79 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
24 |
15 |
$2K |
| D0330 |
Panoramic radiographic image |
39 |
39 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
28 |
28 |
$359.24 |