| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
919 |
848 |
$29K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
232 |
100 |
$26K |
| D1206 |
Topical application of fluoride varnish |
1,034 |
955 |
$21K |
| D9248 |
|
250 |
200 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
591 |
524 |
$16K |
| D0330 |
Panoramic radiographic image |
364 |
309 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
401 |
397 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
131 |
77 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
137 |
56 |
$7K |
| D1351 |
Sealant - per tooth |
169 |
39 |
$4K |
| D0272 |
Bitewings - two radiographic images |
256 |
215 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
49 |
25 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
142 |
131 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
85 |
80 |
$2K |
| D1110 |
Prophylaxis - adult |
30 |
30 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
54 |
53 |
$666.12 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$342.72 |