| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,177 |
3,071 |
$180K |
| D0120 |
Periodic oral evaluation - established patient |
2,371 |
2,311 |
$63K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
495 |
200 |
$57K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,247 |
3,135 |
$57K |
| D0330 |
Panoramic radiographic image |
441 |
428 |
$26K |
| D0272 |
Bitewings - two radiographic images |
1,149 |
1,129 |
$25K |
| D7140 |
Extraction, erupted tooth or exposed root |
301 |
157 |
$24K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
740 |
719 |
$23K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
609 |
562 |
$23K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
122 |
97 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
486 |
468 |
$5K |
| D1351 |
Sealant - per tooth |
125 |
40 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
59 |
40 |
$3K |
| D0274 |
Bitewings - four radiographic images |
31 |
30 |
$1K |
| D1354 |
|
71 |
17 |
$875.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
75 |
50 |
$487.50 |
| D0603 |
|
17 |
17 |
$0.00 |