| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,652 |
3,648 |
$145K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,194 |
290 |
$123K |
| D1206 |
Topical application of fluoride varnish |
3,564 |
3,561 |
$67K |
| D0120 |
Periodic oral evaluation - established patient |
2,255 |
2,255 |
$62K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,312 |
992 |
$33K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
667 |
662 |
$25K |
| D0272 |
Bitewings - two radiographic images |
1,335 |
1,330 |
$23K |
| D0220 |
Intraoral - periapical first radiographic image |
1,313 |
1,267 |
$20K |
| D0603 |
|
2,618 |
2,612 |
$18K |
| D0240 |
|
708 |
408 |
$11K |
| D7140 |
Extraction, erupted tooth or exposed root |
101 |
41 |
$9K |
| D0145 |
Oral evaluation for a patient under three years of age |
275 |
275 |
$7K |
| D1351 |
Sealant - per tooth |
184 |
65 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
89 |
46 |
$6K |
| D0602 |
|
615 |
615 |
$4K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
156 |
151 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
116 |
107 |
$4K |
| D1999 |
|
430 |
407 |
$1K |
| D0330 |
Panoramic radiographic image |
25 |
25 |
$897.00 |
| D1320 |
|
28 |
28 |
$270.00 |
| D1354 |
|
40 |
15 |
$64.40 |
| D1330 |
|
2,543 |
2,539 |
$10.08 |
| D1310 |
|
2,590 |
2,582 |
$0.00 |