| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,411 |
1,395 |
$50K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
300 |
79 |
$34K |
| D0120 |
Periodic oral evaluation - established patient |
1,403 |
1,387 |
$31K |
| D1206 |
Topical application of fluoride varnish |
1,527 |
1,506 |
$26K |
| D0272 |
Bitewings - two radiographic images |
941 |
933 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
165 |
98 |
$12K |
| D7140 |
Extraction, erupted tooth or exposed root |
141 |
71 |
$9K |
| D1110 |
Prophylaxis - adult |
177 |
175 |
$8K |
| D0330 |
Panoramic radiographic image |
102 |
97 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
113 |
73 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
211 |
206 |
$6K |
| D1351 |
Sealant - per tooth |
239 |
79 |
$6K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
150 |
143 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
188 |
188 |
$4K |
| D0240 |
|
74 |
50 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
79 |
72 |
$884.00 |
| D0140 |
Limited oral evaluation - problem focused |
14 |
14 |
$347.38 |