| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
824 |
811 |
$46K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
721 |
708 |
$22K |
| D0330 |
Panoramic radiographic image |
347 |
340 |
$19K |
| D1206 |
Topical application of fluoride varnish |
878 |
863 |
$15K |
| D1351 |
Sealant - per tooth |
609 |
156 |
$13K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
107 |
32 |
$12K |
| D7140 |
Extraction, erupted tooth or exposed root |
129 |
64 |
$10K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
246 |
229 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
947 |
248 |
$8K |
| D0272 |
Bitewings - two radiographic images |
362 |
357 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
184 |
182 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
77 |
44 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
336 |
319 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
61 |
56 |
$3K |
| D0274 |
Bitewings - four radiographic images |
47 |
44 |
$1K |
| D3120 |
|
111 |
62 |
$763.32 |