| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,982 |
2,808 |
$119K |
| D1206 |
Topical application of fluoride varnish |
2,946 |
2,774 |
$74K |
| D0120 |
Periodic oral evaluation - established patient |
2,233 |
2,097 |
$61K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
635 |
459 |
$36K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,115 |
1,027 |
$23K |
| D7140 |
Extraction, erupted tooth or exposed root |
347 |
264 |
$18K |
| D1351 |
Sealant - per tooth |
296 |
155 |
$17K |
| D0274 |
Bitewings - four radiographic images |
1,013 |
951 |
$16K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
132 |
94 |
$15K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
378 |
306 |
$13K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
504 |
396 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,290 |
1,031 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
1,494 |
1,368 |
$8K |
| D0272 |
Bitewings - two radiographic images |
585 |
552 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
311 |
290 |
$5K |
| D1354 |
|
129 |
73 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
159 |
147 |
$2K |
| D1510 |
|
22 |
22 |
$2K |
| D0330 |
Panoramic radiographic image |
40 |
39 |
$858.80 |
| D0270 |
|
116 |
107 |
$616.00 |
| D1999 |
|
918 |
751 |
$0.00 |