| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
854 |
854 |
$41K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
244 |
151 |
$33K |
| D1206 |
Topical application of fluoride varnish |
1,192 |
1,192 |
$31K |
| D1351 |
Sealant - per tooth |
688 |
132 |
$27K |
| D0120 |
Periodic oral evaluation - established patient |
823 |
823 |
$26K |
| D0330 |
Panoramic radiographic image |
265 |
265 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
173 |
173 |
$10K |
| D7140 |
Extraction, erupted tooth or exposed root |
64 |
39 |
$9K |
| D0272 |
Bitewings - two radiographic images |
529 |
529 |
$9K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
407 |
384 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
39 |
25 |
$4K |
| D0274 |
Bitewings - four radiographic images |
159 |
159 |
$4K |
| D1110 |
Prophylaxis - adult |
24 |
24 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
47 |
47 |
$531.90 |