| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1354 |
|
3,171 |
652 |
$232K |
| D1120 |
Prophylaxis - child |
2,110 |
2,009 |
$75K |
| D1206 |
Topical application of fluoride varnish |
2,418 |
2,296 |
$53K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
928 |
875 |
$34K |
| D0120 |
Periodic oral evaluation - established patient |
1,437 |
1,366 |
$34K |
| D0272 |
Bitewings - two radiographic images |
962 |
906 |
$21K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
547 |
464 |
$16K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
58 |
29 |
$9K |
| D1110 |
Prophylaxis - adult |
132 |
125 |
$7K |
| D1351 |
Sealant - per tooth |
220 |
52 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
50 |
27 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
99 |
92 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
17 |
12 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
23 |
15 |
$1K |
| D0274 |
Bitewings - four radiographic images |
43 |
41 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
136 |
41 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
28 |
25 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
94 |
88 |
$970.36 |