| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
980 |
948 |
$44K |
| D1206 |
Topical application of fluoride varnish |
941 |
907 |
$36K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
114 |
41 |
$31K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
354 |
341 |
$25K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
355 |
282 |
$19K |
| D0120 |
Periodic oral evaluation - established patient |
378 |
376 |
$13K |
| D0272 |
Bitewings - two radiographic images |
319 |
311 |
$11K |
| D7140 |
Extraction, erupted tooth or exposed root |
43 |
24 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
139 |
137 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
35 |
27 |
$3K |
| D0330 |
Panoramic radiographic image |
48 |
48 |
$2K |
| D1351 |
Sealant - per tooth |
41 |
16 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
13 |
13 |
$613.00 |
| D0274 |
Bitewings - four radiographic images |
13 |
13 |
$257.00 |