| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D9248 |
|
89 |
89 |
$24K |
| D0120 |
Periodic oral evaluation - established patient |
616 |
607 |
$19K |
| D1120 |
Prophylaxis - child |
511 |
504 |
$18K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
162 |
68 |
$18K |
| D1206 |
Topical application of fluoride varnish |
740 |
731 |
$16K |
| D7140 |
Extraction, erupted tooth or exposed root |
166 |
74 |
$11K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
118 |
59 |
$9K |
| D2140 |
|
107 |
57 |
$7K |
| D1110 |
Prophylaxis - adult |
112 |
112 |
$6K |
| D0272 |
Bitewings - two radiographic images |
270 |
267 |
$6K |
| D1351 |
Sealant - per tooth |
153 |
29 |
$5K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
98 |
95 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
86 |
86 |
$4K |
| D1510 |
|
19 |
13 |
$4K |
| D0274 |
Bitewings - four radiographic images |
117 |
117 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
23 |
14 |
$2K |
| D0330 |
Panoramic radiographic image |
16 |
16 |
$591.00 |
| D0220 |
Intraoral - periapical first radiographic image |
59 |
59 |
$590.00 |