| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
966 |
933 |
$40K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
315 |
95 |
$19K |
| D1120 |
Prophylaxis - child |
737 |
716 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
117 |
117 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,049 |
1,013 |
$8K |
| D1110 |
Prophylaxis - adult |
269 |
259 |
$6K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
238 |
208 |
$5K |
| D1351 |
Sealant - per tooth |
63 |
19 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
51 |
33 |
$2K |
| D0330 |
Panoramic radiographic image |
158 |
153 |
$2K |
| D0272 |
Bitewings - two radiographic images |
296 |
292 |
$2K |
| D9248 |
|
15 |
12 |
$881.40 |
| D7140 |
Extraction, erupted tooth or exposed root |
22 |
13 |
$529.14 |
| D0274 |
Bitewings - four radiographic images |
45 |
42 |
$245.25 |
| D0220 |
Intraoral - periapical first radiographic image |
14 |
14 |
$65.45 |