| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
971 |
956 |
$38K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
237 |
94 |
$27K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
740 |
725 |
$19K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
184 |
119 |
$12K |
| D1208 |
Topical application of fluoride, excluding varnish |
709 |
694 |
$10K |
| D0272 |
Bitewings - two radiographic images |
631 |
622 |
$9K |
| D7140 |
Extraction, erupted tooth or exposed root |
182 |
95 |
$9K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
229 |
199 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
183 |
180 |
$5K |
| D1351 |
Sealant - per tooth |
273 |
90 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
460 |
448 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
255 |
253 |
$4K |
| D1206 |
Topical application of fluoride varnish |
291 |
291 |
$4K |
| D0330 |
Panoramic radiographic image |
113 |
111 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
561 |
366 |
$4K |