| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
403 |
399 |
$8K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
55 |
17 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
311 |
308 |
$5K |
| D1206 |
Topical application of fluoride varnish |
333 |
330 |
$5K |
| D0330 |
Panoramic radiographic image |
65 |
64 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
115 |
115 |
$3K |
| D0272 |
Bitewings - two radiographic images |
266 |
260 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
46 |
26 |
$2K |
| D1351 |
Sealant - per tooth |
97 |
29 |
$2K |
| D0240 |
|
126 |
65 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
23 |
15 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
74 |
74 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
19 |
13 |
$870.57 |
| D0140 |
Limited oral evaluation - problem focused |
29 |
27 |
$654.82 |
| D0220 |
Intraoral - periapical first radiographic image |
97 |
91 |
$460.00 |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$409.56 |
| D0274 |
Bitewings - four radiographic images |
15 |
15 |
$240.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
39 |
15 |
$185.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
15 |
15 |
$0.00 |
| D1330 |
|
19 |
19 |
$0.00 |