| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
7,942 |
7,721 |
$64K |
| D1206 |
Topical application of fluoride varnish |
9,225 |
8,973 |
$38K |
| D0120 |
Periodic oral evaluation - established patient |
7,477 |
7,286 |
$37K |
| D0230 |
Intraoral - periapical each additional radiographic image |
8,417 |
5,859 |
$26K |
| D0220 |
Intraoral - periapical first radiographic image |
6,770 |
6,526 |
$19K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
961 |
427 |
$17K |
| D0272 |
Bitewings - two radiographic images |
2,828 |
2,751 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,289 |
1,259 |
$13K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
298 |
102 |
$8K |
| D1110 |
Prophylaxis - adult |
770 |
742 |
$6K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,276 |
1,184 |
$5K |
| D0274 |
Bitewings - four radiographic images |
1,037 |
1,008 |
$5K |
| D0330 |
Panoramic radiographic image |
774 |
741 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
64 |
41 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
80 |
42 |
$2K |
| D1351 |
Sealant - per tooth |
487 |
165 |
$2K |
| D0350 |
|
240 |
107 |
$810.19 |
| D0140 |
Limited oral evaluation - problem focused |
57 |
57 |
$424.44 |
| D1999 |
|
72 |
68 |
$0.00 |
| D1330 |
|
3,835 |
3,513 |
$0.00 |
| D0601 |
|
14 |
12 |
$0.00 |