| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,170 |
1,938 |
$89K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
429 |
108 |
$74K |
| D1206 |
Topical application of fluoride varnish |
2,347 |
2,104 |
$63K |
| D0120 |
Periodic oral evaluation - established patient |
1,831 |
1,643 |
$55K |
| D0272 |
Bitewings - two radiographic images |
1,394 |
1,247 |
$38K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
473 |
431 |
$21K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
136 |
64 |
$15K |
| D0240 |
|
376 |
197 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
629 |
552 |
$12K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
343 |
300 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
625 |
203 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
59 |
29 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
49 |
25 |
$4K |
| D1351 |
Sealant - per tooth |
147 |
51 |
$4K |
| D9420 |
|
16 |
12 |
$2K |
| D1110 |
Prophylaxis - adult |
28 |
24 |
$986.65 |