| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,486 |
2,452 |
$97K |
| D0120 |
Periodic oral evaluation - established patient |
2,112 |
2,089 |
$64K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
421 |
151 |
$43K |
| D1206 |
Topical application of fluoride varnish |
2,434 |
2,397 |
$39K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
526 |
319 |
$37K |
| D0272 |
Bitewings - two radiographic images |
1,550 |
1,530 |
$37K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
904 |
803 |
$21K |
| D1351 |
Sealant - per tooth |
452 |
157 |
$15K |
| D0210 |
Intraoral - complete series of radiographic images |
177 |
177 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
738 |
697 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
242 |
230 |
$11K |
| D7140 |
Extraction, erupted tooth or exposed root |
244 |
105 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
161 |
117 |
$10K |
| D0274 |
Bitewings - four radiographic images |
206 |
201 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
408 |
306 |
$3K |
| D0145 |
Oral evaluation for a patient under three years of age |
12 |
12 |
$360.00 |