| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
1,158 |
195 |
$46K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
163 |
71 |
$29K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
495 |
495 |
$28K |
| D7140 |
Extraction, erupted tooth or exposed root |
191 |
83 |
$26K |
| D1120 |
Prophylaxis - child |
517 |
517 |
$25K |
| D1206 |
Topical application of fluoride varnish |
573 |
573 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
95 |
58 |
$13K |
| D0330 |
Panoramic radiographic image |
133 |
133 |
$6K |
| D0272 |
Bitewings - two radiographic images |
370 |
370 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
92 |
91 |
$4K |
| D0145 |
Oral evaluation for a patient under three years of age |
93 |
93 |
$4K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
188 |
170 |
$4K |
| D1110 |
Prophylaxis - adult |
44 |
44 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
23 |
13 |
$2K |
| D0274 |
Bitewings - four radiographic images |
46 |
46 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
53 |
50 |
$626.46 |
| D0240 |
|
31 |
31 |
$486.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
13 |
13 |
$203.36 |