| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,710 |
2,688 |
$139K |
| D0120 |
Periodic oral evaluation - established patient |
1,518 |
1,518 |
$104K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
871 |
868 |
$58K |
| D0230 |
Intraoral - periapical each additional radiographic image |
12,902 |
2,442 |
$54K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,693 |
2,690 |
$47K |
| D1351 |
Sealant - per tooth |
1,018 |
391 |
$39K |
| D1310 |
|
643 |
643 |
$29K |
| D0274 |
Bitewings - four radiographic images |
987 |
986 |
$21K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
202 |
111 |
$14K |
| D0603 |
|
547 |
547 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
132 |
89 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
506 |
506 |
$6K |
| D0272 |
Bitewings - two radiographic images |
444 |
443 |
$5K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
65 |
32 |
$4K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
107 |
104 |
$4K |
| D0350 |
|
421 |
241 |
$4K |
| D1320 |
|
329 |
329 |
$3K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
21 |
12 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
16 |
12 |
$918.40 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$455.00 |
| D0602 |
|
15 |
15 |
$225.00 |