| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,725 |
2,671 |
$122K |
| D1206 |
Topical application of fluoride varnish |
2,713 |
2,661 |
$96K |
| D1351 |
Sealant - per tooth |
3,084 |
652 |
$67K |
| D0230 |
Intraoral - periapical each additional radiographic image |
7,683 |
2,255 |
$44K |
| D0274 |
Bitewings - four radiographic images |
1,617 |
1,567 |
$37K |
| D0120 |
Periodic oral evaluation - established patient |
1,333 |
1,318 |
$34K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,027 |
999 |
$33K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
414 |
126 |
$28K |
| D7140 |
Extraction, erupted tooth or exposed root |
472 |
190 |
$19K |
| D0220 |
Intraoral - periapical first radiographic image |
1,375 |
1,342 |
$18K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
245 |
120 |
$13K |
| D9999 |
Unspecified adjunctive procedure, by report |
179 |
179 |
$10K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
471 |
417 |
$8K |
| D0145 |
Oral evaluation for a patient under three years of age |
192 |
192 |
$4K |
| D0999 |
Unspecified diagnostic procedure, by report |
85 |
85 |
$3K |
| D0603 |
|
828 |
804 |
$776.00 |
| D0602 |
|
570 |
567 |
$564.00 |
| D9420 |
|
13 |
12 |
$516.48 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$452.04 |
| D0601 |
|
29 |
28 |
$26.00 |
| D9986 |
|
13 |
13 |
$0.00 |