| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,137 |
1,061 |
$36K |
| D1206 |
Topical application of fluoride varnish |
1,144 |
1,072 |
$23K |
| D0120 |
Periodic oral evaluation - established patient |
1,093 |
1,033 |
$23K |
| D1351 |
Sealant - per tooth |
865 |
217 |
$22K |
| D0272 |
Bitewings - two radiographic images |
757 |
724 |
$13K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
96 |
53 |
$12K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
435 |
407 |
$11K |
| D1110 |
Prophylaxis - adult |
214 |
214 |
$9K |
| D2140 |
|
145 |
106 |
$6K |
| D0274 |
Bitewings - four radiographic images |
213 |
213 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
730 |
690 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
145 |
140 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
122 |
121 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
203 |
202 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
568 |
506 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
24 |
13 |
$899.76 |
| D0140 |
Limited oral evaluation - problem focused |
24 |
24 |
$74.16 |
| D1999 |
|
1,099 |
1,045 |
$0.00 |