| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
740 |
695 |
$22K |
| D1206 |
Topical application of fluoride varnish |
870 |
821 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
578 |
538 |
$16K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
101 |
54 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
148 |
89 |
$10K |
| D7140 |
Extraction, erupted tooth or exposed root |
112 |
53 |
$10K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
220 |
198 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
221 |
210 |
$8K |
| D0272 |
Bitewings - two radiographic images |
354 |
325 |
$5K |
| D1351 |
Sealant - per tooth |
87 |
31 |
$3K |
| D1110 |
Prophylaxis - adult |
38 |
38 |
$2K |
| D0240 |
|
59 |
29 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
22 |
17 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
33 |
24 |
$722.56 |
| D0220 |
Intraoral - periapical first radiographic image |
83 |
73 |
$457.10 |
| D0230 |
Intraoral - periapical each additional radiographic image |
73 |
63 |
$399.40 |