| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,051 |
1,041 |
$48K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
586 |
572 |
$32K |
| D1206 |
Topical application of fluoride varnish |
1,259 |
1,244 |
$31K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
185 |
127 |
$24K |
| D0120 |
Periodic oral evaluation - established patient |
560 |
560 |
$18K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
77 |
26 |
$13K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
400 |
346 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
62 |
33 |
$7K |
| D1351 |
Sealant - per tooth |
174 |
63 |
$6K |
| D1330 |
|
692 |
678 |
$4K |
| D0272 |
Bitewings - two radiographic images |
226 |
226 |
$4K |
| D0330 |
Panoramic radiographic image |
31 |
31 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
28 |
27 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
29 |
29 |
$287.62 |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$276.00 |
| D0240 |
|
13 |
12 |
$162.00 |