| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
674 |
672 |
$33K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
291 |
152 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
617 |
615 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
195 |
112 |
$11K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
233 |
224 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
433 |
432 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
112 |
60 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
622 |
192 |
$5K |
| D0272 |
Bitewings - two radiographic images |
271 |
270 |
$4K |
| D1206 |
Topical application of fluoride varnish |
293 |
290 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
146 |
144 |
$4K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
30 |
12 |
$3K |
| D1110 |
Prophylaxis - adult |
66 |
65 |
$3K |
| D1351 |
Sealant - per tooth |
195 |
86 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
264 |
251 |
$3K |
| D0330 |
Panoramic radiographic image |
38 |
38 |
$1K |
| D0274 |
Bitewings - four radiographic images |
66 |
65 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
31 |
31 |
$991.65 |