| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
6,846 |
6,823 |
$194K |
| D1206 |
Topical application of fluoride varnish |
6,682 |
6,552 |
$168K |
| D0120 |
Periodic oral evaluation - established patient |
5,807 |
5,785 |
$140K |
| D1351 |
Sealant - per tooth |
2,286 |
692 |
$58K |
| D1999 |
|
4,317 |
4,166 |
$43K |
| D0272 |
Bitewings - two radiographic images |
2,866 |
2,851 |
$35K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,088 |
1,047 |
$31K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
181 |
53 |
$25K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
948 |
944 |
$22K |
| D1208 |
Topical application of fluoride, excluding varnish |
776 |
749 |
$17K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
113 |
73 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
1,258 |
1,236 |
$8K |
| D0330 |
Panoramic radiographic image |
329 |
323 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
82 |
52 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
891 |
510 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
76 |
76 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
112 |
112 |
$3K |
| D0145 |
Oral evaluation for a patient under three years of age |
58 |
58 |
$2K |
| D1354 |
|
169 |
52 |
$2K |
| D1110 |
Prophylaxis - adult |
64 |
63 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
17 |
14 |
$961.38 |
| D0274 |
Bitewings - four radiographic images |
28 |
28 |
$441.14 |