| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
852 |
726 |
$31K |
| D1206 |
Topical application of fluoride varnish |
924 |
778 |
$26K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
272 |
90 |
$10K |
| D0272 |
Bitewings - two radiographic images |
620 |
522 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
303 |
277 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
299 |
257 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
532 |
412 |
$8K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
186 |
63 |
$8K |
| D1351 |
Sealant - per tooth |
447 |
145 |
$8K |
| D0330 |
Panoramic radiographic image |
179 |
143 |
$6K |
| D2140 |
|
175 |
77 |
$5K |
| D9248 |
|
110 |
70 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
194 |
67 |
$4K |
| D0603 |
|
849 |
716 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
342 |
221 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
134 |
104 |
$1K |
| D0274 |
Bitewings - four radiographic images |
70 |
48 |
$1K |
| D0240 |
|
70 |
60 |
$820.12 |
| D0601 |
|
81 |
62 |
$300.00 |
| D3120 |
|
45 |
12 |
$90.00 |