| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,095 |
1,079 |
$32K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
267 |
112 |
$28K |
| D0120 |
Periodic oral evaluation - established patient |
1,316 |
1,301 |
$28K |
| D1206 |
Topical application of fluoride varnish |
1,605 |
1,578 |
$27K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
298 |
295 |
$13K |
| D7140 |
Extraction, erupted tooth or exposed root |
170 |
100 |
$12K |
| D0272 |
Bitewings - two radiographic images |
646 |
639 |
$10K |
| D1110 |
Prophylaxis - adult |
148 |
148 |
$6K |
| D1351 |
Sealant - per tooth |
201 |
91 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
170 |
169 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
42 |
38 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
270 |
268 |
$2K |
| D0330 |
Panoramic radiographic image |
57 |
57 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
39 |
39 |
$864.64 |
| D1208 |
Topical application of fluoride, excluding varnish |
26 |
26 |
$502.08 |
| D1354 |
|
22 |
12 |
$492.70 |