| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,696 |
1,660 |
$91K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
435 |
253 |
$68K |
| D1110 |
Prophylaxis - adult |
345 |
333 |
$32K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
320 |
171 |
$23K |
| D0230 |
Intraoral - periapical each additional radiographic image |
897 |
868 |
$21K |
| D7140 |
Extraction, erupted tooth or exposed root |
320 |
174 |
$17K |
| D0999 |
Unspecified diagnostic procedure, by report |
347 |
284 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
1,864 |
1,820 |
$12K |
| D1354 |
|
463 |
185 |
$10K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
593 |
491 |
$4K |
| D1351 |
Sealant - per tooth |
866 |
227 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
54 |
54 |
$3K |
| D0274 |
Bitewings - four radiographic images |
673 |
653 |
$2K |
| D0272 |
Bitewings - two radiographic images |
875 |
853 |
$935.98 |
| D1208 |
Topical application of fluoride, excluding varnish |
228 |
226 |
$862.96 |
| D1330 |
|
1,877 |
1,829 |
$670.76 |
| D1999 |
|
223 |
192 |
$604.26 |
| D0220 |
Intraoral - periapical first radiographic image |
1,102 |
1,068 |
$481.04 |
| D1206 |
Topical application of fluoride varnish |
1,813 |
1,762 |
$224.17 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$114.18 |