| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,133 |
1,130 |
$64K |
| D1206 |
Topical application of fluoride varnish |
1,119 |
1,116 |
$59K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
500 |
259 |
$40K |
| D1351 |
Sealant - per tooth |
1,657 |
586 |
$34K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
577 |
575 |
$19K |
| D0120 |
Periodic oral evaluation - established patient |
496 |
496 |
$16K |
| D0272 |
Bitewings - two radiographic images |
621 |
618 |
$13K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
573 |
530 |
$10K |
| D0330 |
Panoramic radiographic image |
227 |
226 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
510 |
509 |
$9K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
110 |
82 |
$9K |
| D0274 |
Bitewings - four radiographic images |
353 |
353 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
131 |
81 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
778 |
530 |
$4K |
| D1353 |
|
262 |
132 |
$4K |
| D0240 |
|
263 |
162 |
$3K |
| D0350 |
|
237 |
196 |
$3K |
| D2140 |
|
42 |
31 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
12 |
12 |
$246.00 |