| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,807 |
2,623 |
$110K |
| D1206 |
Topical application of fluoride varnish |
2,651 |
2,487 |
$66K |
| D0120 |
Periodic oral evaluation - established patient |
2,370 |
2,226 |
$64K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
336 |
202 |
$36K |
| D1351 |
Sealant - per tooth |
597 |
291 |
$32K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
323 |
212 |
$18K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,674 |
1,529 |
$18K |
| D7140 |
Extraction, erupted tooth or exposed root |
338 |
217 |
$16K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
536 |
498 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
610 |
560 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
1,852 |
1,704 |
$10K |
| D0272 |
Bitewings - two radiographic images |
684 |
621 |
$6K |
| D0330 |
Panoramic radiographic image |
206 |
188 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
157 |
149 |
$2K |
| D0274 |
Bitewings - four radiographic images |
64 |
54 |
$1K |
| D1999 |
|
112 |
90 |
$0.00 |