| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,303 |
1,302 |
$49K |
| D1206 |
Topical application of fluoride varnish |
1,375 |
1,375 |
$40K |
| D1351 |
Sealant - per tooth |
819 |
246 |
$35K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
148 |
65 |
$29K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
548 |
548 |
$27K |
| D0120 |
Periodic oral evaluation - established patient |
764 |
764 |
$25K |
| D0330 |
Panoramic radiographic image |
270 |
270 |
$24K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
185 |
110 |
$19K |
| D7140 |
Extraction, erupted tooth or exposed root |
131 |
83 |
$15K |
| D0272 |
Bitewings - two radiographic images |
708 |
708 |
$13K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
117 |
71 |
$11K |
| D0240 |
|
297 |
152 |
$7K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
88 |
85 |
$5K |
| D1354 |
|
149 |
51 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
96 |
94 |
$4K |
| D0274 |
Bitewings - four radiographic images |
96 |
96 |
$3K |
| D1110 |
Prophylaxis - adult |
39 |
39 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
78 |
75 |
$756.91 |