| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,899 |
2,719 |
$107K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
640 |
183 |
$92K |
| D0120 |
Periodic oral evaluation - established patient |
3,448 |
3,227 |
$79K |
| D1206 |
Topical application of fluoride varnish |
3,451 |
3,226 |
$73K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
950 |
909 |
$31K |
| D0272 |
Bitewings - two radiographic images |
743 |
698 |
$17K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
509 |
458 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
172 |
101 |
$14K |
| D7140 |
Extraction, erupted tooth or exposed root |
76 |
13 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
56 |
50 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
37 |
12 |
$2K |
| D0330 |
Panoramic radiographic image |
29 |
28 |
$2K |
| D1110 |
Prophylaxis - adult |
30 |
28 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
49 |
15 |
$310.00 |
| D0220 |
Intraoral - periapical first radiographic image |
29 |
29 |
$304.75 |
| D0240 |
|
13 |
12 |
$240.50 |