| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,476 |
3,473 |
$102K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,606 |
4,602 |
$79K |
| D0120 |
Periodic oral evaluation - established patient |
3,201 |
3,200 |
$66K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,431 |
1,430 |
$48K |
| D0272 |
Bitewings - two radiographic images |
1,963 |
1,961 |
$38K |
| D0140 |
Limited oral evaluation - problem focused |
871 |
863 |
$25K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
922 |
860 |
$25K |
| D1110 |
Prophylaxis - adult |
807 |
807 |
$24K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
178 |
39 |
$19K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
210 |
153 |
$13K |
| D0274 |
Bitewings - four radiographic images |
146 |
146 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
42 |
26 |
$2K |
| D0240 |
|
166 |
108 |
$2K |
| D0330 |
Panoramic radiographic image |
37 |
37 |
$2K |
| D9420 |
|
12 |
12 |
$878.15 |