| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
442 |
441 |
$19K |
| D1206 |
Topical application of fluoride varnish |
492 |
491 |
$18K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
121 |
40 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
457 |
457 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
101 |
81 |
$11K |
| D7140 |
Extraction, erupted tooth or exposed root |
110 |
45 |
$9K |
| D1351 |
Sealant - per tooth |
250 |
89 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
78 |
68 |
$6K |
| D1110 |
Prophylaxis - adult |
93 |
93 |
$6K |
| D0272 |
Bitewings - two radiographic images |
162 |
162 |
$4K |
| D0274 |
Bitewings - four radiographic images |
95 |
95 |
$3K |
| D9420 |
|
13 |
13 |
$3K |
| D0330 |
Panoramic radiographic image |
41 |
41 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
64 |
64 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
47 |
47 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
42 |
41 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
30 |
30 |
$870.00 |
| D0220 |
Intraoral - periapical first radiographic image |
57 |
57 |
$855.00 |