| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
4,231 |
4,088 |
$113K |
| D0120 |
Periodic oral evaluation - established patient |
3,622 |
3,500 |
$70K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
615 |
156 |
$33K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
694 |
680 |
$28K |
| D7140 |
Extraction, erupted tooth or exposed root |
777 |
339 |
$17K |
| D1206 |
Topical application of fluoride varnish |
4,099 |
3,964 |
$17K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
167 |
93 |
$11K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
962 |
893 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,311 |
995 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
180 |
95 |
$7K |
| D1351 |
Sealant - per tooth |
1,885 |
524 |
$5K |
| D0272 |
Bitewings - two radiographic images |
3,213 |
3,098 |
$5K |
| D0330 |
Panoramic radiographic image |
52 |
52 |
$3K |
| D1330 |
|
4,301 |
4,159 |
$2K |
| D1354 |
|
199 |
42 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
117 |
115 |
$1K |
| D9999 |
Unspecified adjunctive procedure, by report |
44 |
44 |
$950.00 |
| D0220 |
Intraoral - periapical first radiographic image |
1,461 |
1,398 |
$939.98 |
| D9420 |
|
26 |
25 |
$0.00 |