| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,428 |
1,428 |
$77K |
| D1206 |
Topical application of fluoride varnish |
1,690 |
1,688 |
$53K |
| D0120 |
Periodic oral evaluation - established patient |
1,399 |
1,398 |
$43K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
276 |
162 |
$35K |
| D1110 |
Prophylaxis - adult |
363 |
362 |
$26K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
414 |
414 |
$23K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
93 |
26 |
$18K |
| D0272 |
Bitewings - two radiographic images |
573 |
573 |
$13K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
297 |
293 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
58 |
30 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
180 |
180 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
367 |
364 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
321 |
320 |
$5K |
| D1351 |
Sealant - per tooth |
125 |
50 |
$4K |
| D0145 |
Oral evaluation for a patient under three years of age |
127 |
127 |
$4K |
| D0274 |
Bitewings - four radiographic images |
131 |
130 |
$4K |
| D0330 |
Panoramic radiographic image |
54 |
54 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
23 |
13 |
$2K |
| D0240 |
|
39 |
39 |
$1K |