| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,111 |
2,111 |
$80K |
| D0120 |
Periodic oral evaluation - established patient |
2,099 |
2,099 |
$64K |
| D1206 |
Topical application of fluoride varnish |
2,322 |
2,322 |
$59K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
196 |
89 |
$36K |
| D0272 |
Bitewings - two radiographic images |
1,041 |
1,041 |
$25K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
248 |
123 |
$22K |
| D0140 |
Limited oral evaluation - problem focused |
193 |
193 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
70 |
70 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
15 |
12 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
22 |
12 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
92 |
91 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
17 |
12 |
$1K |
| D2140 |
|
27 |
12 |
$1K |
| D1351 |
Sealant - per tooth |
42 |
12 |
$1K |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$348.00 |
| D0240 |
|
14 |
13 |
$308.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
27 |
27 |
$0.00 |