| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
626 |
624 |
$32K |
| D0120 |
Periodic oral evaluation - established patient |
545 |
544 |
$21K |
| D1206 |
Topical application of fluoride varnish |
620 |
619 |
$21K |
| D1351 |
Sealant - per tooth |
489 |
116 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
135 |
71 |
$11K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
193 |
185 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
71 |
39 |
$6K |
| D0274 |
Bitewings - four radiographic images |
124 |
124 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
45 |
28 |
$3K |
| D0603 |
|
467 |
465 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
67 |
67 |
$3K |
| D0272 |
Bitewings - two radiographic images |
118 |
118 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
170 |
168 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
215 |
210 |
$2K |
| D0330 |
Panoramic radiographic image |
29 |
29 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
33 |
31 |
$2K |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$720.00 |
| D0240 |
|
15 |
15 |
$270.00 |
| D9920 |
|
16 |
13 |
$75.00 |