| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
6,190 |
5,478 |
$178K |
| D1206 |
Topical application of fluoride varnish |
7,719 |
6,834 |
$139K |
| D0120 |
Periodic oral evaluation - established patient |
7,271 |
6,438 |
$138K |
| D1351 |
Sealant - per tooth |
2,890 |
483 |
$67K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
433 |
110 |
$45K |
| D0272 |
Bitewings - two radiographic images |
2,205 |
1,940 |
$41K |
| D1110 |
Prophylaxis - adult |
968 |
862 |
$37K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
922 |
818 |
$22K |
| D0140 |
Limited oral evaluation - problem focused |
645 |
519 |
$17K |
| D0330 |
Panoramic radiographic image |
309 |
279 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,855 |
448 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
324 |
193 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
233 |
153 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
1,008 |
886 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
417 |
361 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
99 |
26 |
$3K |
| D0274 |
Bitewings - four radiographic images |
27 |
13 |
$281.36 |
| D1330 |
|
648 |
583 |
$0.00 |