| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,573 |
1,563 |
$31K |
| D1206 |
Topical application of fluoride varnish |
1,581 |
1,573 |
$24K |
| D0120 |
Periodic oral evaluation - established patient |
1,196 |
1,187 |
$20K |
| D7140 |
Extraction, erupted tooth or exposed root |
186 |
78 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
324 |
324 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
159 |
115 |
$9K |
| D0272 |
Bitewings - two radiographic images |
741 |
734 |
$7K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
42 |
14 |
$4K |
| D0330 |
Panoramic radiographic image |
72 |
72 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
121 |
117 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
19 |
13 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
155 |
150 |
$805.50 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
14 |
14 |
$0.00 |