| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,949 |
1,947 |
$56K |
| D1120 |
Prophylaxis - child |
1,009 |
1,009 |
$46K |
| D1351 |
Sealant - per tooth |
1,520 |
306 |
$44K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,398 |
1,397 |
$40K |
| D1110 |
Prophylaxis - adult |
766 |
764 |
$35K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
636 |
528 |
$28K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
431 |
295 |
$28K |
| D0274 |
Bitewings - four radiographic images |
428 |
426 |
$17K |
| D1330 |
|
1,032 |
1,032 |
$11K |
| D1310 |
|
978 |
978 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
173 |
134 |
$10K |
| D0272 |
Bitewings - two radiographic images |
320 |
320 |
$9K |
| D0330 |
Panoramic radiographic image |
62 |
62 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
15 |
12 |
$978.25 |