| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,586 |
2,582 |
$99K |
| D0120 |
Periodic oral evaluation - established patient |
2,203 |
2,197 |
$59K |
| D1351 |
Sealant - per tooth |
966 |
343 |
$33K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
459 |
310 |
$31K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,710 |
1,709 |
$31K |
| D7140 |
Extraction, erupted tooth or exposed root |
282 |
155 |
$22K |
| D0272 |
Bitewings - two radiographic images |
1,096 |
1,094 |
$21K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
673 |
638 |
$17K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
439 |
438 |
$16K |
| D0140 |
Limited oral evaluation - problem focused |
335 |
327 |
$11K |
| D0240 |
|
698 |
370 |
$11K |
| D1206 |
Topical application of fluoride varnish |
586 |
584 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
585 |
563 |
$7K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
44 |
25 |
$4K |
| D1354 |
|
1,906 |
517 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
321 |
157 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
14 |
12 |
$784.00 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$624.00 |