| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
794 |
771 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
953 |
923 |
$17K |
| D1206 |
Topical application of fluoride varnish |
842 |
815 |
$12K |
| D1351 |
Sealant - per tooth |
518 |
128 |
$9K |
| D1110 |
Prophylaxis - adult |
227 |
216 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
408 |
293 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
437 |
421 |
$5K |
| D0272 |
Bitewings - two radiographic images |
262 |
258 |
$5K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
41 |
13 |
$3K |
| D0274 |
Bitewings - four radiographic images |
75 |
74 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
21 |
12 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
39 |
39 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
24 |
24 |
$554.93 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
34 |
26 |
$533.28 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$414.45 |
| D1208 |
Topical application of fluoride, excluding varnish |
13 |
13 |
$114.64 |