| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,056 |
1,056 |
$45K |
| D1206 |
Topical application of fluoride varnish |
996 |
996 |
$27K |
| D0120 |
Periodic oral evaluation - established patient |
890 |
890 |
$26K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
349 |
344 |
$21K |
| D1351 |
Sealant - per tooth |
296 |
146 |
$17K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
547 |
547 |
$14K |
| D0272 |
Bitewings - two radiographic images |
993 |
993 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
94 |
72 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
1,022 |
1,021 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
87 |
70 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
897 |
895 |
$4K |
| D0330 |
Panoramic radiographic image |
148 |
148 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
66 |
57 |
$3K |
| D0274 |
Bitewings - four radiographic images |
166 |
166 |
$3K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
38 |
27 |
$3K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
13 |
12 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
97 |
97 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
37 |
37 |
$782.52 |
| D1354 |
|
36 |
31 |
$712.80 |