| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
654 |
638 |
$20K |
| D1206 |
Topical application of fluoride varnish |
946 |
916 |
$18K |
| D0120 |
Periodic oral evaluation - established patient |
598 |
576 |
$13K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
54 |
13 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
75 |
33 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
387 |
376 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
121 |
120 |
$3K |
| D1110 |
Prophylaxis - adult |
95 |
89 |
$3K |
| D1351 |
Sealant - per tooth |
169 |
45 |
$3K |
| D0272 |
Bitewings - two radiographic images |
198 |
195 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
362 |
342 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
22 |
14 |
$1K |
| D8670 |
Periodic orthodontic treatment visit |
15 |
12 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
34 |
34 |
$965.25 |
| D0330 |
Panoramic radiographic image |
15 |
15 |
$473.71 |
| D0274 |
Bitewings - four radiographic images |
15 |
15 |
$339.36 |