| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
744 |
744 |
$27K |
| D1206 |
Topical application of fluoride varnish |
716 |
716 |
$16K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
69 |
62 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
372 |
372 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
546 |
545 |
$14K |
| D0272 |
Bitewings - two radiographic images |
405 |
405 |
$10K |
| D1351 |
Sealant - per tooth |
145 |
79 |
$9K |
| D0274 |
Bitewings - four radiographic images |
232 |
232 |
$9K |
| D2140 |
|
105 |
95 |
$7K |
| D1110 |
Prophylaxis - adult |
163 |
163 |
$6K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
210 |
204 |
$5K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
45 |
43 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
44 |
34 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
126 |
124 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$510.23 |