| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
7,446 |
7,424 |
$258K |
| D0120 |
Periodic oral evaluation - established patient |
8,399 |
8,374 |
$205K |
| D1206 |
Topical application of fluoride varnish |
9,948 |
9,920 |
$198K |
| D1110 |
Prophylaxis - adult |
2,202 |
2,195 |
$107K |
| D0272 |
Bitewings - two radiographic images |
1,713 |
1,711 |
$36K |
| D0210 |
Intraoral - complete series of radiographic images |
436 |
436 |
$36K |
| D0274 |
Bitewings - four radiographic images |
860 |
855 |
$27K |
| D1351 |
Sealant - per tooth |
613 |
136 |
$21K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
525 |
523 |
$21K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
108 |
40 |
$14K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
274 |
270 |
$9K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
49 |
24 |
$8K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
49 |
12 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
317 |
315 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
15 |
12 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
39 |
39 |
$618.47 |
| D0240 |
|
15 |
14 |
$286.95 |