| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,780 |
1,582 |
$77K |
| D0120 |
Periodic oral evaluation - established patient |
3,119 |
2,727 |
$70K |
| D1120 |
Prophylaxis - child |
2,035 |
1,783 |
$60K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,914 |
2,566 |
$35K |
| D1351 |
Sealant - per tooth |
1,617 |
404 |
$33K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
484 |
266 |
$28K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
233 |
116 |
$20K |
| D0274 |
Bitewings - four radiographic images |
689 |
606 |
$17K |
| D0272 |
Bitewings - two radiographic images |
793 |
673 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
420 |
402 |
$12K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
91 |
37 |
$10K |
| D0330 |
Panoramic radiographic image |
351 |
305 |
$10K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
402 |
294 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
70 |
40 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
19 |
18 |
$328.30 |
| D0220 |
Intraoral - periapical first radiographic image |
36 |
34 |
$321.32 |
| D0603 |
|
513 |
484 |
$0.00 |
| D0602 |
|
3,245 |
2,829 |
$0.00 |