| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,573 |
1,548 |
$28K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,685 |
1,659 |
$23K |
| D0120 |
Periodic oral evaluation - established patient |
1,318 |
1,300 |
$20K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
275 |
272 |
$7K |
| D0272 |
Bitewings - two radiographic images |
738 |
726 |
$7K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
44 |
12 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
59 |
43 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
27 |
12 |
$2K |
| D1351 |
Sealant - per tooth |
74 |
28 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
24 |
13 |
$1K |
| D0330 |
Panoramic radiographic image |
24 |
24 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
112 |
109 |
$540.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
528 |
483 |
$0.00 |
| D1999 |
|
20 |
16 |
$0.00 |