| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
4,643 |
4,605 |
$233K |
| D1206 |
Topical application of fluoride varnish |
5,481 |
5,433 |
$140K |
| D0120 |
Periodic oral evaluation - established patient |
3,772 |
3,729 |
$105K |
| D1351 |
Sealant - per tooth |
1,485 |
432 |
$56K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
527 |
252 |
$55K |
| D0272 |
Bitewings - two radiographic images |
1,506 |
1,494 |
$44K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
484 |
237 |
$40K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
498 |
493 |
$28K |
| D1110 |
Prophylaxis - adult |
334 |
324 |
$19K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
93 |
51 |
$18K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
744 |
706 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
769 |
750 |
$15K |
| D7140 |
Extraction, erupted tooth or exposed root |
76 |
41 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
459 |
324 |
$6K |
| D0330 |
Panoramic radiographic image |
81 |
78 |
$6K |
| D0274 |
Bitewings - four radiographic images |
138 |
134 |
$5K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
23 |
15 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
36 |
36 |
$2K |
| D9248 |
|
15 |
15 |
$675.00 |
| D1999 |
|
34 |
33 |
$0.00 |