| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
670 |
593 |
$25K |
| D1206 |
Topical application of fluoride varnish |
899 |
809 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
395 |
368 |
$11K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
37 |
12 |
$5K |
| D3120 |
|
138 |
39 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
80 |
76 |
$4K |
| D0272 |
Bitewings - two radiographic images |
256 |
242 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
81 |
79 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
30 |
14 |
$3K |
| D1351 |
Sealant - per tooth |
83 |
28 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
127 |
107 |
$2K |
| D1330 |
|
393 |
362 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
23 |
16 |
$2K |
| D9310 |
|
43 |
41 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$108.00 |