| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,288 |
1,288 |
$42K |
| D0120 |
Periodic oral evaluation - established patient |
1,443 |
1,443 |
$28K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
129 |
39 |
$17K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
196 |
125 |
$17K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
225 |
147 |
$16K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
438 |
402 |
$14K |
| D0272 |
Bitewings - two radiographic images |
734 |
734 |
$14K |
| D7140 |
Extraction, erupted tooth or exposed root |
113 |
37 |
$7K |
| D1110 |
Prophylaxis - adult |
139 |
139 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
126 |
126 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
347 |
345 |
$4K |
| D1351 |
Sealant - per tooth |
37 |
12 |
$1K |
| D0330 |
Panoramic radiographic image |
14 |
14 |
$755.86 |
| D0230 |
Intraoral - periapical each additional radiographic image |
63 |
37 |
$637.26 |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$249.48 |