| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,322 |
1,303 |
$15K |
| D1206 |
Topical application of fluoride varnish |
1,267 |
1,248 |
$9K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
67 |
56 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
435 |
428 |
$7K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
545 |
505 |
$7K |
| D0272 |
Bitewings - two radiographic images |
622 |
617 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
198 |
159 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
888 |
876 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,013 |
709 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
818 |
805 |
$4K |
| D1351 |
Sealant - per tooth |
508 |
186 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
131 |
111 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
52 |
40 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
15 |
14 |
$0.00 |