| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,821 |
1,699 |
$74K |
| D1206 |
Topical application of fluoride varnish |
1,817 |
1,699 |
$59K |
| D0120 |
Periodic oral evaluation - established patient |
1,559 |
1,464 |
$36K |
| D1351 |
Sealant - per tooth |
1,655 |
422 |
$34K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
497 |
274 |
$23K |
| D0272 |
Bitewings - two radiographic images |
1,264 |
1,180 |
$21K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
595 |
525 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
264 |
152 |
$9K |
| D7140 |
Extraction, erupted tooth or exposed root |
184 |
128 |
$7K |
| D0274 |
Bitewings - four radiographic images |
280 |
254 |
$6K |
| D0330 |
Panoramic radiographic image |
160 |
149 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
159 |
141 |
$4K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
61 |
40 |
$4K |
| D1353 |
|
548 |
203 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
54 |
51 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
110 |
105 |
$1K |
| D0240 |
|
31 |
29 |
$727.65 |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$567.00 |
| D0603 |
|
461 |
408 |
$259.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
49 |
41 |
$251.99 |
| D0602 |
|
211 |
193 |
$113.00 |
| D0601 |
|
133 |
117 |
$57.00 |
| D9986 |
|
420 |
404 |
$0.00 |