| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
814 |
792 |
$25K |
| D0120 |
Periodic oral evaluation - established patient |
565 |
551 |
$12K |
| D1208 |
Topical application of fluoride, excluding varnish |
665 |
643 |
$12K |
| D0272 |
Bitewings - two radiographic images |
323 |
313 |
$7K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
74 |
35 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
161 |
154 |
$6K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
222 |
211 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
21 |
14 |
$1K |
| D2330 |
|
21 |
12 |
$867.00 |
| D7140 |
Extraction, erupted tooth or exposed root |
17 |
13 |
$340.00 |
| D1110 |
Prophylaxis - adult |
13 |
12 |
$165.00 |
| D1206 |
Topical application of fluoride varnish |
13 |
12 |
$160.00 |
| D0220 |
Intraoral - periapical first radiographic image |
14 |
14 |
$112.00 |
| D1330 |
|
937 |
905 |
$0.00 |