| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,678 |
1,657 |
$78K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,004 |
1,966 |
$50K |
| D7140 |
Extraction, erupted tooth or exposed root |
660 |
298 |
$31K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
368 |
244 |
$25K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
640 |
603 |
$21K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
149 |
76 |
$17K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
272 |
186 |
$15K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,048 |
1,033 |
$15K |
| D1206 |
Topical application of fluoride varnish |
854 |
836 |
$12K |
| D0272 |
Bitewings - two radiographic images |
592 |
586 |
$10K |
| D1110 |
Prophylaxis - adult |
203 |
202 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
176 |
166 |
$5K |
| D0274 |
Bitewings - four radiographic images |
187 |
180 |
$5K |
| D0330 |
Panoramic radiographic image |
90 |
84 |
$3K |
| D1351 |
Sealant - per tooth |
159 |
55 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
243 |
235 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
31 |
28 |
$648.00 |
| D9248 |
|
14 |
13 |
$312.00 |