| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,933 |
2,800 |
$96K |
| D0120 |
Periodic oral evaluation - established patient |
2,852 |
2,731 |
$75K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
455 |
136 |
$55K |
| D1351 |
Sealant - per tooth |
2,309 |
516 |
$55K |
| D0272 |
Bitewings - two radiographic images |
2,029 |
1,950 |
$43K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,238 |
2,336 |
$32K |
| D0220 |
Intraoral - periapical first radiographic image |
2,764 |
2,579 |
$31K |
| D1206 |
Topical application of fluoride varnish |
1,984 |
1,920 |
$27K |
| D0145 |
Oral evaluation for a patient under three years of age |
174 |
169 |
$22K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
203 |
126 |
$17K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,152 |
1,079 |
$15K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
531 |
481 |
$13K |
| D7140 |
Extraction, erupted tooth or exposed root |
263 |
93 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
198 |
186 |
$6K |
| D0330 |
Panoramic radiographic image |
42 |
41 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
89 |
87 |
$1K |
| D1110 |
Prophylaxis - adult |
27 |
27 |
$1K |
| D1330 |
|
1,254 |
1,239 |
$657.75 |
| D0274 |
Bitewings - four radiographic images |
13 |
13 |
$416.93 |
| D0603 |
|
4,063 |
3,938 |
$0.00 |