| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
5,760 |
5,752 |
$183K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,197 |
3,197 |
$112K |
| D1208 |
Topical application of fluoride, excluding varnish |
5,892 |
5,886 |
$108K |
| D0272 |
Bitewings - two radiographic images |
3,228 |
3,223 |
$66K |
| D0120 |
Periodic oral evaluation - established patient |
2,760 |
2,753 |
$63K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
705 |
445 |
$52K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
394 |
186 |
$47K |
| D0220 |
Intraoral - periapical first radiographic image |
3,682 |
3,657 |
$42K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
565 |
300 |
$31K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,016 |
998 |
$28K |
| D1351 |
Sealant - per tooth |
615 |
217 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,332 |
1,327 |
$12K |
| D7140 |
Extraction, erupted tooth or exposed root |
44 |
24 |
$3K |
| D9420 |
|
24 |
24 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
37 |
37 |
$1K |
| D1110 |
Prophylaxis - adult |
16 |
16 |
$671.70 |