| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,476 |
2,383 |
$96K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
548 |
239 |
$62K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,453 |
2,365 |
$61K |
| D0120 |
Periodic oral evaluation - established patient |
2,212 |
2,135 |
$59K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
640 |
581 |
$16K |
| D0272 |
Bitewings - two radiographic images |
1,115 |
1,062 |
$10K |
| D7140 |
Extraction, erupted tooth or exposed root |
151 |
75 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
381 |
359 |
$8K |
| D1351 |
Sealant - per tooth |
144 |
70 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
66 |
54 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
569 |
538 |
$3K |
| D0330 |
Panoramic radiographic image |
55 |
55 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
166 |
144 |
$809.40 |
| D0140 |
Limited oral evaluation - problem focused |
14 |
14 |
$162.00 |