| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1354 |
|
1,918 |
472 |
$69K |
| D1120 |
Prophylaxis - child |
1,253 |
1,161 |
$48K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
255 |
47 |
$39K |
| D1206 |
Topical application of fluoride varnish |
1,418 |
1,312 |
$31K |
| D7140 |
Extraction, erupted tooth or exposed root |
216 |
76 |
$27K |
| D0120 |
Periodic oral evaluation - established patient |
1,001 |
934 |
$26K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
307 |
122 |
$22K |
| D0272 |
Bitewings - two radiographic images |
482 |
451 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
104 |
47 |
$10K |
| D1351 |
Sealant - per tooth |
393 |
83 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
173 |
147 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
62 |
58 |
$4K |
| D1110 |
Prophylaxis - adult |
56 |
56 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
65 |
62 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
95 |
88 |
$3K |
| D0240 |
|
127 |
118 |
$3K |
| D0330 |
Panoramic radiographic image |
50 |
43 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
30 |
29 |
$1K |