| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
605 |
541 |
$23K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
346 |
184 |
$22K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
759 |
682 |
$16K |
| D0330 |
Panoramic radiographic image |
433 |
394 |
$15K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
142 |
81 |
$15K |
| D1351 |
Sealant - per tooth |
935 |
194 |
$14K |
| D0272 |
Bitewings - two radiographic images |
635 |
574 |
$10K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
233 |
206 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
612 |
548 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
150 |
90 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
117 |
67 |
$5K |
| D1110 |
Prophylaxis - adult |
89 |
84 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
102 |
84 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
349 |
302 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
389 |
237 |
$2K |
| D2330 |
|
23 |
13 |
$972.40 |
| D1206 |
Topical application of fluoride varnish |
51 |
49 |
$688.67 |