| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
1,280 |
1,267 |
$79K |
| D1120 |
Prophylaxis - child |
1,387 |
1,362 |
$37K |
| D7140 |
Extraction, erupted tooth or exposed root |
238 |
121 |
$22K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
467 |
447 |
$22K |
| D0120 |
Periodic oral evaluation - established patient |
662 |
658 |
$19K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
73 |
54 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
177 |
177 |
$7K |
| D0272 |
Bitewings - two radiographic images |
421 |
420 |
$6K |
| D1351 |
Sealant - per tooth |
86 |
37 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
29 |
24 |
$3K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
20 |
12 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
116 |
113 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
57 |
57 |
$804.00 |