| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,523 |
2,366 |
$16K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,070 |
2,213 |
$10K |
| D1206 |
Topical application of fluoride varnish |
2,590 |
2,448 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
1,974 |
1,875 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
565 |
551 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
2,546 |
2,410 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
440 |
245 |
$4K |
| D1351 |
Sealant - per tooth |
905 |
272 |
$4K |
| D0274 |
Bitewings - four radiographic images |
543 |
523 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
101 |
52 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
571 |
493 |
$2K |
| D0330 |
Panoramic radiographic image |
253 |
246 |
$1K |
| D0272 |
Bitewings - two radiographic images |
427 |
409 |
$809.64 |
| D1110 |
Prophylaxis - adult |
86 |
86 |
$738.26 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
95 |
55 |
$702.48 |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
28 |
12 |
$557.67 |
| D1208 |
Topical application of fluoride, excluding varnish |
131 |
131 |
$90.27 |
| D1330 |
|
1,649 |
1,590 |
$0.00 |
| D0602 |
|
13 |
13 |
$0.00 |