| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
5,447 |
4,677 |
$142K |
| D0120 |
Periodic oral evaluation - established patient |
3,906 |
3,439 |
$97K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,530 |
3,153 |
$56K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
435 |
246 |
$45K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
944 |
732 |
$30K |
| D0272 |
Bitewings - two radiographic images |
1,489 |
1,356 |
$29K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
334 |
213 |
$29K |
| D7140 |
Extraction, erupted tooth or exposed root |
298 |
135 |
$23K |
| D1206 |
Topical application of fluoride varnish |
1,124 |
875 |
$21K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,453 |
1,237 |
$20K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
164 |
44 |
$18K |
| D0330 |
Panoramic radiographic image |
155 |
148 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
447 |
413 |
$5K |
| D0274 |
Bitewings - four radiographic images |
132 |
111 |
$3K |
| D1351 |
Sealant - per tooth |
73 |
26 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
41 |
37 |
$2K |
| D1110 |
Prophylaxis - adult |
39 |
28 |
$694.04 |
| D1999 |
|
107 |
77 |
$0.00 |