| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,024 |
1,957 |
$108K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
452 |
162 |
$52K |
| D1206 |
Topical application of fluoride varnish |
2,016 |
1,952 |
$30K |
| D0120 |
Periodic oral evaluation - established patient |
1,249 |
1,211 |
$28K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
364 |
204 |
$24K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
779 |
747 |
$23K |
| D0272 |
Bitewings - two radiographic images |
809 |
777 |
$14K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
415 |
345 |
$14K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
248 |
149 |
$13K |
| D7140 |
Extraction, erupted tooth or exposed root |
185 |
79 |
$10K |
| D0330 |
Panoramic radiographic image |
129 |
123 |
$6K |
| D1351 |
Sealant - per tooth |
273 |
86 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
111 |
107 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
28 |
28 |
$915.10 |
| D0230 |
Intraoral - periapical each additional radiographic image |
18 |
12 |
$117.00 |
| D9420 |
|
13 |
13 |
$0.00 |