| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
7,917 |
7,805 |
$352K |
| D1206 |
Topical application of fluoride varnish |
8,547 |
8,425 |
$213K |
| D0120 |
Periodic oral evaluation - established patient |
6,529 |
6,445 |
$197K |
| D1351 |
Sealant - per tooth |
2,039 |
447 |
$70K |
| D0272 |
Bitewings - two radiographic images |
2,666 |
2,613 |
$41K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
750 |
736 |
$39K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
266 |
163 |
$33K |
| D1330 |
|
4,308 |
4,240 |
$27K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,422 |
1,316 |
$27K |
| D0330 |
Panoramic radiographic image |
407 |
396 |
$17K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
88 |
15 |
$15K |
| D7140 |
Extraction, erupted tooth or exposed root |
88 |
38 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
248 |
246 |
$2K |
| D2940 |
|
46 |
24 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
50 |
50 |
$2K |
| D3120 |
|
45 |
14 |
$2K |
| D0274 |
Bitewings - four radiographic images |
66 |
65 |
$1K |
| D0240 |
|
92 |
90 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
17 |
17 |
$767.52 |
| D9420 |
|
17 |
17 |
$255.00 |