| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,159 |
1,088 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
801 |
747 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
369 |
353 |
$5K |
| D1206 |
Topical application of fluoride varnish |
1,101 |
1,034 |
$4K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
214 |
188 |
$2K |
| D0272 |
Bitewings - two radiographic images |
880 |
821 |
$1K |
| D1330 |
|
1,179 |
1,108 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
99 |
54 |
$1K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
23 |
13 |
$810.90 |
| D0220 |
Intraoral - periapical first radiographic image |
412 |
385 |
$672.32 |
| D0230 |
Intraoral - periapical each additional radiographic image |
287 |
255 |
$669.78 |
| D1351 |
Sealant - per tooth |
183 |
59 |
$479.72 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
26 |
15 |
$265.90 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
17 |
12 |
$216.56 |
| D1354 |
|
28 |
12 |
$77.64 |
| D0140 |
Limited oral evaluation - problem focused |
40 |
36 |
$45.88 |