| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
482 |
482 |
$22K |
| D1120 |
Prophylaxis - child |
560 |
560 |
$21K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
111 |
66 |
$15K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
390 |
334 |
$13K |
| D1206 |
Topical application of fluoride varnish |
678 |
678 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
83 |
60 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
562 |
532 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
615 |
425 |
$8K |
| D0330 |
Panoramic radiographic image |
116 |
116 |
$7K |
| D1110 |
Prophylaxis - adult |
96 |
96 |
$5K |
| D0145 |
Oral evaluation for a patient under three years of age |
64 |
64 |
$4K |
| D0272 |
Bitewings - two radiographic images |
204 |
204 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
24 |
13 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
96 |
96 |
$3K |
| D1351 |
Sealant - per tooth |
77 |
26 |
$2K |
| D0274 |
Bitewings - four radiographic images |
53 |
53 |
$2K |