| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
542 |
540 |
$17K |
| D1208 |
Topical application of fluoride, excluding varnish |
594 |
589 |
$11K |
| D1351 |
Sealant - per tooth |
359 |
63 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
347 |
345 |
$7K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
125 |
118 |
$5K |
| D0272 |
Bitewings - two radiographic images |
237 |
234 |
$4K |
| D8670 |
Periodic orthodontic treatment visit |
34 |
34 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
170 |
169 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
50 |
30 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
26 |
13 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
21 |
13 |
$1K |
| D1110 |
Prophylaxis - adult |
16 |
16 |
$576.00 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$336.00 |