| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
450 |
450 |
$15K |
| D1206 |
Topical application of fluoride varnish |
550 |
550 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
121 |
57 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
428 |
428 |
$9K |
| D9920 |
|
82 |
80 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
118 |
118 |
$4K |
| D1110 |
Prophylaxis - adult |
76 |
76 |
$4K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
26 |
13 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
52 |
26 |
$4K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
96 |
91 |
$3K |
| D0272 |
Bitewings - two radiographic images |
150 |
150 |
$3K |
| D1351 |
Sealant - per tooth |
91 |
31 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
38 |
25 |
$3K |
| D0274 |
Bitewings - four radiographic images |
33 |
33 |
$910.80 |
| D0220 |
Intraoral - periapical first radiographic image |
27 |
26 |
$301.86 |
| D0240 |
|
21 |
15 |
$257.67 |