| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,013 |
1,001 |
$53K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
649 |
333 |
$43K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
330 |
134 |
$37K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
881 |
860 |
$24K |
| D7140 |
Extraction, erupted tooth or exposed root |
532 |
229 |
$23K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
413 |
341 |
$15K |
| D1208 |
Topical application of fluoride, excluding varnish |
985 |
974 |
$14K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
215 |
140 |
$12K |
| D0272 |
Bitewings - two radiographic images |
583 |
574 |
$10K |
| D1351 |
Sealant - per tooth |
407 |
159 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
355 |
353 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
774 |
749 |
$7K |
| D0330 |
Panoramic radiographic image |
172 |
168 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
790 |
644 |
$5K |
| D0274 |
Bitewings - four radiographic images |
45 |
40 |
$823.55 |
| D9248 |
|
13 |
12 |
$507.00 |
| D0145 |
Oral evaluation for a patient under three years of age |
12 |
12 |
$314.75 |