| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
578 |
577 |
$27K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
335 |
325 |
$19K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
75 |
30 |
$15K |
| D1206 |
Topical application of fluoride varnish |
431 |
431 |
$14K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
101 |
56 |
$11K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
216 |
181 |
$9K |
| D0272 |
Bitewings - two radiographic images |
333 |
327 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
243 |
243 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
280 |
273 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
47 |
27 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
83 |
83 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
25 |
25 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
104 |
84 |
$2K |
| D1351 |
Sealant - per tooth |
32 |
12 |
$1K |
| D0330 |
Panoramic radiographic image |
14 |
14 |
$1K |