| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,521 |
1,521 |
$45K |
| D0120 |
Periodic oral evaluation - established patient |
1,998 |
1,998 |
$41K |
| D1110 |
Prophylaxis - adult |
865 |
865 |
$38K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,249 |
2,249 |
$33K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,027 |
847 |
$27K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
451 |
247 |
$26K |
| D0274 |
Bitewings - four radiographic images |
511 |
511 |
$15K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
159 |
103 |
$14K |
| D0272 |
Bitewings - two radiographic images |
670 |
670 |
$12K |
| D1351 |
Sealant - per tooth |
433 |
182 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
98 |
49 |
$7K |
| D2140 |
|
100 |
51 |
$6K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
50 |
25 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
124 |
124 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
53 |
25 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
33 |
33 |
$478.83 |