| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
417 |
416 |
$17K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
140 |
91 |
$16K |
| D1206 |
Topical application of fluoride varnish |
542 |
540 |
$13K |
| D0120 |
Periodic oral evaluation - established patient |
431 |
431 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
97 |
77 |
$9K |
| D1351 |
Sealant - per tooth |
131 |
48 |
$4K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
187 |
167 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
58 |
57 |
$3K |
| D1110 |
Prophylaxis - adult |
47 |
47 |
$3K |
| D0272 |
Bitewings - two radiographic images |
164 |
163 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
21 |
12 |
$2K |
| D0330 |
Panoramic radiographic image |
48 |
48 |
$2K |
| D1330 |
|
288 |
287 |
$2K |
| D1352 |
|
34 |
17 |
$1K |
| D0274 |
Bitewings - four radiographic images |
47 |
47 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
31 |
27 |
$279.00 |