| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,558 |
2,185 |
$83K |
| D1206 |
Topical application of fluoride varnish |
2,842 |
2,457 |
$56K |
| D0120 |
Periodic oral evaluation - established patient |
2,093 |
1,806 |
$55K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
224 |
60 |
$42K |
| D0272 |
Bitewings - two radiographic images |
985 |
888 |
$21K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
251 |
219 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
278 |
260 |
$14K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
81 |
40 |
$12K |
| D0240 |
|
324 |
175 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
43 |
12 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
214 |
199 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
227 |
88 |
$3K |
| D9420 |
|
31 |
24 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
51 |
24 |
$997.04 |