| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,370 |
1,365 |
$47K |
| D0120 |
Periodic oral evaluation - established patient |
1,305 |
1,304 |
$35K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
256 |
166 |
$19K |
| D1208 |
Topical application of fluoride, excluding varnish |
962 |
962 |
$19K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
265 |
170 |
$16K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
374 |
355 |
$13K |
| D0272 |
Bitewings - two radiographic images |
655 |
653 |
$13K |
| D1206 |
Topical application of fluoride varnish |
505 |
505 |
$12K |
| D0330 |
Panoramic radiographic image |
195 |
195 |
$11K |
| D1110 |
Prophylaxis - adult |
192 |
192 |
$9K |
| D0145 |
Oral evaluation for a patient under three years of age |
191 |
189 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
279 |
276 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
52 |
28 |
$3K |
| D1351 |
Sealant - per tooth |
90 |
30 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
25 |
25 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
66 |
66 |
$990.00 |