| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,239 |
3,143 |
$155K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,924 |
3,805 |
$103K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,501 |
716 |
$102K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
765 |
401 |
$41K |
| D7140 |
Extraction, erupted tooth or exposed root |
801 |
424 |
$39K |
| D0272 |
Bitewings - two radiographic images |
2,096 |
2,028 |
$37K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
291 |
121 |
$33K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,529 |
1,477 |
$22K |
| D1206 |
Topical application of fluoride varnish |
1,253 |
1,225 |
$19K |
| D0330 |
Panoramic radiographic image |
251 |
245 |
$16K |
| D1110 |
Prophylaxis - adult |
275 |
259 |
$12K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
263 |
257 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
632 |
603 |
$6K |
| D0274 |
Bitewings - four radiographic images |
144 |
139 |
$4K |
| D2331 |
|
46 |
24 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
65 |
64 |
$1K |
| D9420 |
|
13 |
13 |
$878.80 |
| D1351 |
Sealant - per tooth |
33 |
12 |
$585.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
65 |
26 |
$492.00 |
| D9986 |
|
389 |
277 |
$0.00 |
| D1999 |
|
89 |
71 |
$0.00 |