| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
489 |
473 |
$24K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
129 |
69 |
$24K |
| D0210 |
Intraoral - complete series of radiographic images |
151 |
143 |
$20K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
125 |
80 |
$14K |
| D1110 |
Prophylaxis - adult |
160 |
155 |
$13K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
124 |
87 |
$5K |
| D9248 |
|
165 |
158 |
$5K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
74 |
70 |
$1K |
| D1351 |
Sealant - per tooth |
224 |
68 |
$682.92 |
| D1120 |
Prophylaxis - child |
380 |
367 |
$269.52 |
| D0240 |
|
405 |
215 |
$57.08 |
| D0272 |
Bitewings - two radiographic images |
300 |
291 |
$51.74 |
| D1206 |
Topical application of fluoride varnish |
510 |
493 |
$49.94 |
| D0220 |
Intraoral - periapical first radiographic image |
58 |
55 |
$42.84 |
| D7140 |
Extraction, erupted tooth or exposed root |
45 |
27 |
$0.00 |
| D1330 |
|
520 |
503 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
33 |
33 |
$0.00 |