| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,917 |
2,884 |
$97K |
| D0120 |
Periodic oral evaluation - established patient |
2,754 |
2,721 |
$65K |
| D1206 |
Topical application of fluoride varnish |
3,153 |
3,116 |
$60K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
405 |
153 |
$44K |
| D0272 |
Bitewings - two radiographic images |
1,074 |
1,062 |
$21K |
| D1351 |
Sealant - per tooth |
529 |
127 |
$11K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
479 |
462 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
289 |
284 |
$7K |
| D1110 |
Prophylaxis - adult |
180 |
175 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
66 |
47 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
492 |
478 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
99 |
51 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
63 |
46 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
412 |
293 |
$3K |
| D0330 |
Panoramic radiographic image |
114 |
112 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
57 |
56 |
$2K |
| D0274 |
Bitewings - four radiographic images |
46 |
45 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$614.04 |