| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
7,329 |
7,178 |
$247K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,676 |
398 |
$188K |
| D1206 |
Topical application of fluoride varnish |
7,818 |
7,641 |
$164K |
| D0120 |
Periodic oral evaluation - established patient |
5,653 |
5,561 |
$138K |
| D0230 |
Intraoral - periapical each additional radiographic image |
10,031 |
3,239 |
$92K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,493 |
2,409 |
$70K |
| D4346 |
|
1,305 |
1,267 |
$57K |
| D0220 |
Intraoral - periapical first radiographic image |
3,997 |
3,828 |
$49K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
614 |
312 |
$46K |
| D7140 |
Extraction, erupted tooth or exposed root |
607 |
223 |
$37K |
| D0330 |
Panoramic radiographic image |
796 |
779 |
$30K |
| D9248 |
|
338 |
319 |
$29K |
| D1351 |
Sealant - per tooth |
961 |
299 |
$26K |
| D0272 |
Bitewings - two radiographic images |
1,501 |
1,456 |
$25K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
299 |
162 |
$19K |
| D1110 |
Prophylaxis - adult |
278 |
271 |
$12K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
377 |
347 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
71 |
68 |
$2K |
| D0274 |
Bitewings - four radiographic images |
16 |
14 |
$336.40 |
| D9420 |
|
153 |
151 |
$100.00 |
| D1999 |
|
32 |
32 |
$0.00 |