| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,049 |
1,031 |
$37K |
| D1110 |
Prophylaxis - adult |
400 |
397 |
$23K |
| D0603 |
|
1,149 |
1,132 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,452 |
1,374 |
$6K |
| D0274 |
Bitewings - four radiographic images |
596 |
590 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
1,315 |
1,303 |
$5K |
| D1206 |
Topical application of fluoride varnish |
1,550 |
1,528 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
75 |
75 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
93 |
73 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
255 |
255 |
$3K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
22 |
15 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
295 |
281 |
$2K |
| D0272 |
Bitewings - two radiographic images |
733 |
720 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
2,117 |
2,064 |
$911.27 |
| D1351 |
Sealant - per tooth |
142 |
40 |
$674.55 |
| D1330 |
|
1,545 |
1,524 |
$580.08 |
| D7140 |
Extraction, erupted tooth or exposed root |
14 |
12 |
$389.75 |
| D1354 |
|
89 |
12 |
$360.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
16 |
13 |
$357.40 |
| D1208 |
Topical application of fluoride, excluding varnish |
29 |
29 |
$49.05 |
| D0330 |
Panoramic radiographic image |
28 |
24 |
$0.00 |