| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
633 |
553 |
$26K |
| D1206 |
Topical application of fluoride varnish |
603 |
527 |
$20K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
327 |
288 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
151 |
70 |
$7K |
| D0272 |
Bitewings - two radiographic images |
469 |
419 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
291 |
252 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
773 |
530 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
424 |
365 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
81 |
48 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
192 |
163 |
$3K |
| D1351 |
Sealant - per tooth |
117 |
31 |
$3K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
39 |
17 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
70 |
32 |
$2K |
| D0330 |
Panoramic radiographic image |
59 |
57 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
26 |
26 |
$831.00 |
| D0601 |
|
87 |
85 |
$420.00 |
| D9310 |
|
14 |
14 |
$120.00 |