| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,761 |
2,750 |
$117K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
607 |
304 |
$93K |
| D0120 |
Periodic oral evaluation - established patient |
3,170 |
3,156 |
$92K |
| D1351 |
Sealant - per tooth |
2,769 |
555 |
$92K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
476 |
363 |
$57K |
| D1206 |
Topical application of fluoride varnish |
2,076 |
2,076 |
$52K |
| D1110 |
Prophylaxis - adult |
661 |
657 |
$38K |
| D7140 |
Extraction, erupted tooth or exposed root |
323 |
181 |
$33K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,382 |
1,367 |
$32K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
289 |
214 |
$27K |
| D0330 |
Panoramic radiographic image |
509 |
506 |
$21K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
129 |
117 |
$19K |
| D0272 |
Bitewings - two radiographic images |
1,155 |
1,150 |
$17K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
301 |
297 |
$16K |
| D1330 |
|
1,812 |
1,805 |
$11K |
| D0274 |
Bitewings - four radiographic images |
467 |
465 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
236 |
234 |
$10K |
| D3120 |
|
272 |
114 |
$10K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
425 |
400 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
231 |
222 |
$2K |
| D0240 |
|
26 |
26 |
$414.00 |