| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
762 |
756 |
$44K |
| D0120 |
Periodic oral evaluation - established patient |
694 |
691 |
$19K |
| D1208 |
Topical application of fluoride, excluding varnish |
826 |
820 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
146 |
99 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
174 |
115 |
$9K |
| D1351 |
Sealant - per tooth |
399 |
113 |
$9K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
218 |
211 |
$8K |
| D0330 |
Panoramic radiographic image |
109 |
107 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
89 |
66 |
$7K |
| D1110 |
Prophylaxis - adult |
114 |
113 |
$6K |
| D0272 |
Bitewings - two radiographic images |
290 |
288 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
177 |
173 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
112 |
108 |
$5K |
| D0274 |
Bitewings - four radiographic images |
86 |
84 |
$3K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
15 |
13 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
140 |
135 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
18 |
12 |
$167.70 |