| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
462 |
462 |
$19K |
| D1110 |
Prophylaxis - adult |
260 |
260 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
455 |
455 |
$12K |
| D1351 |
Sealant - per tooth |
240 |
62 |
$10K |
| D0274 |
Bitewings - four radiographic images |
312 |
312 |
$9K |
| D0330 |
Panoramic radiographic image |
188 |
188 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
529 |
529 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
232 |
232 |
$6K |
| D1354 |
|
145 |
34 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
84 |
52 |
$6K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
27 |
26 |
$4K |
| D1206 |
Topical application of fluoride varnish |
131 |
131 |
$4K |
| D0272 |
Bitewings - two radiographic images |
15 |
15 |
$242.25 |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$198.55 |