| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
347 |
347 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
258 |
258 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
106 |
55 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
387 |
387 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
377 |
377 |
$4K |
| D0274 |
Bitewings - four radiographic images |
139 |
139 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
367 |
367 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
135 |
135 |
$3K |
| D0272 |
Bitewings - two radiographic images |
130 |
130 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
30 |
14 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
68 |
64 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
32 |
17 |
$2K |
| D1110 |
Prophylaxis - adult |
30 |
30 |
$1K |
| D1351 |
Sealant - per tooth |
51 |
15 |
$1K |