| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,511 |
3,470 |
$92K |
| D1206 |
Topical application of fluoride varnish |
3,975 |
3,923 |
$65K |
| D0120 |
Periodic oral evaluation - established patient |
2,959 |
2,922 |
$45K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,039 |
972 |
$22K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
612 |
605 |
$17K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,313 |
797 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
1,497 |
1,464 |
$11K |
| D0272 |
Bitewings - two radiographic images |
231 |
230 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
152 |
112 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
147 |
143 |
$3K |
| D9310 |
|
41 |
41 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
171 |
108 |
$966.00 |
| D1110 |
Prophylaxis - adult |
63 |
63 |
$566.28 |
| D1351 |
Sealant - per tooth |
178 |
67 |
$0.00 |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
97 |
57 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
72 |
55 |
$0.00 |
| D9610 |
|
13 |
13 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
30 |
30 |
$0.00 |