| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,771 |
2,665 |
$99K |
| D1208 |
Topical application of fluoride, excluding varnish |
5,215 |
3,654 |
$91K |
| D0120 |
Periodic oral evaluation - established patient |
4,907 |
3,464 |
$87K |
| D1110 |
Prophylaxis - adult |
1,536 |
1,043 |
$53K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,483 |
1,016 |
$36K |
| D0272 |
Bitewings - two radiographic images |
1,609 |
1,101 |
$29K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
181 |
90 |
$16K |
| D1351 |
Sealant - per tooth |
320 |
28 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
119 |
70 |
$2K |
| D2140 |
|
41 |
12 |
$2K |
| D0274 |
Bitewings - four radiographic images |
68 |
26 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
23 |
13 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
16 |
12 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
17 |
12 |
$482.04 |
| D0240 |
|
26 |
12 |
$351.50 |