| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,224 |
2,197 |
$67K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
526 |
164 |
$54K |
| D1206 |
Topical application of fluoride varnish |
2,424 |
2,389 |
$42K |
| D0120 |
Periodic oral evaluation - established patient |
1,907 |
1,887 |
$41K |
| D0272 |
Bitewings - two radiographic images |
826 |
820 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
442 |
438 |
$12K |
| D1351 |
Sealant - per tooth |
503 |
146 |
$11K |
| D7140 |
Extraction, erupted tooth or exposed root |
170 |
103 |
$10K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
324 |
315 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
82 |
59 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
399 |
393 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
54 |
40 |
$4K |
| D1110 |
Prophylaxis - adult |
77 |
75 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
101 |
100 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
283 |
228 |
$3K |
| D0330 |
Panoramic radiographic image |
89 |
89 |
$2K |
| D0274 |
Bitewings - four radiographic images |
63 |
63 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$591.03 |
| D9420 |
|
13 |
13 |
$532.09 |