| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,604 |
1,563 |
$42K |
| D0120 |
Periodic oral evaluation - established patient |
1,608 |
1,576 |
$42K |
| D7140 |
Extraction, erupted tooth or exposed root |
262 |
139 |
$20K |
| D1206 |
Topical application of fluoride varnish |
1,854 |
1,804 |
$20K |
| D1110 |
Prophylaxis - adult |
360 |
349 |
$11K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
590 |
550 |
$10K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
96 |
38 |
$10K |
| D0170 |
|
335 |
323 |
$6K |
| D1351 |
Sealant - per tooth |
346 |
79 |
$4K |
| D0272 |
Bitewings - two radiographic images |
309 |
300 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
40 |
28 |
$3K |
| D0330 |
Panoramic radiographic image |
63 |
63 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
226 |
206 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
26 |
25 |
$500.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$495.00 |
| D1330 |
|
28 |
27 |
$279.31 |
| D9920 |
|
14 |
14 |
$156.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
25 |
12 |
$110.50 |
| D8670 |
Periodic orthodontic treatment visit |
187 |
174 |
$66.00 |