| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,735 |
2,076 |
$52K |
| D1206 |
Topical application of fluoride varnish |
3,106 |
2,383 |
$38K |
| D0120 |
Periodic oral evaluation - established patient |
2,592 |
2,002 |
$31K |
| D0272 |
Bitewings - two radiographic images |
1,327 |
1,018 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
339 |
278 |
$5K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
273 |
211 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
134 |
110 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
306 |
237 |
$2K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
180 |
80 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
56 |
29 |
$537.00 |
| D7140 |
Extraction, erupted tooth or exposed root |
90 |
57 |
$386.20 |
| D1351 |
Sealant - per tooth |
399 |
68 |
$293.50 |
| D0230 |
Intraoral - periapical each additional radiographic image |
125 |
82 |
$190.00 |
| D0330 |
Panoramic radiographic image |
62 |
62 |
$64.52 |
| D0274 |
Bitewings - four radiographic images |
59 |
59 |
$0.00 |
| D1110 |
Prophylaxis - adult |
151 |
151 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
37 |
27 |
$0.00 |