| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
5,338 |
4,935 |
$171K |
| D1206 |
Topical application of fluoride varnish |
6,276 |
5,790 |
$129K |
| D0120 |
Periodic oral evaluation - established patient |
5,779 |
5,368 |
$124K |
| D0272 |
Bitewings - two radiographic images |
2,604 |
2,413 |
$59K |
| D1110 |
Prophylaxis - adult |
1,056 |
981 |
$48K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
255 |
101 |
$36K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,197 |
1,004 |
$34K |
| D1351 |
Sealant - per tooth |
604 |
172 |
$16K |
| D0330 |
Panoramic radiographic image |
263 |
259 |
$16K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
173 |
99 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
283 |
255 |
$9K |
| D7140 |
Extraction, erupted tooth or exposed root |
127 |
69 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
235 |
218 |
$7K |
| D0274 |
Bitewings - four radiographic images |
143 |
136 |
$5K |
| D0240 |
|
324 |
148 |
$5K |
| D0145 |
Oral evaluation for a patient under three years of age |
146 |
130 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
203 |
178 |
$2K |
| D1999 |
|
1,067 |
895 |
$40.00 |
| D0603 |
|
4,721 |
4,442 |
$0.00 |