| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0240 |
|
304 |
303 |
$6K |
| D1120 |
Prophylaxis - child |
222 |
222 |
$6K |
| D0274 |
Bitewings - four radiographic images |
166 |
165 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
266 |
266 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
186 |
186 |
$3K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
13 |
13 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
87 |
87 |
$3K |
| D1351 |
Sealant - per tooth |
31 |
31 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
12 |
12 |
$2K |
| D0272 |
Bitewings - two radiographic images |
79 |
79 |
$1K |
| D1110 |
Prophylaxis - adult |
46 |
45 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
12 |
12 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
17 |
17 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
43 |
41 |
$867.74 |
| D9630 |
|
12 |
12 |
$344.64 |