| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,619 |
1,544 |
$88K |
| D1206 |
Topical application of fluoride varnish |
1,602 |
1,529 |
$81K |
| D1351 |
Sealant - per tooth |
3,041 |
893 |
$57K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,003 |
978 |
$32K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
304 |
163 |
$25K |
| D0272 |
Bitewings - two radiographic images |
934 |
892 |
$19K |
| D0120 |
Periodic oral evaluation - established patient |
606 |
556 |
$16K |
| D0330 |
Panoramic radiographic image |
422 |
389 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
695 |
651 |
$11K |
| D0274 |
Bitewings - four radiographic images |
488 |
460 |
$11K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
426 |
356 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,187 |
793 |
$7K |
| D1353 |
|
441 |
201 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
139 |
85 |
$5K |
| D0240 |
|
409 |
240 |
$5K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
60 |
42 |
$5K |
| D2140 |
|
90 |
66 |
$5K |
| D0350 |
|
196 |
168 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
26 |
25 |
$797.76 |