| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
4,034 |
4,009 |
$49K |
| D1110 |
Prophylaxis - adult |
1,442 |
1,435 |
$32K |
| D1120 |
Prophylaxis - child |
1,344 |
1,332 |
$24K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
123 |
39 |
$12K |
| D1206 |
Topical application of fluoride varnish |
942 |
939 |
$10K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
161 |
135 |
$4K |
| D1351 |
Sealant - per tooth |
230 |
70 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
249 |
249 |
$2K |
| D0272 |
Bitewings - two radiographic images |
178 |
177 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
80 |
80 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
24 |
15 |
$964.79 |
| D0240 |
|
73 |
43 |
$709.65 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
18 |
13 |
$562.31 |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$541.28 |
| D0274 |
Bitewings - four radiographic images |
39 |
39 |
$506.70 |
| D0140 |
Limited oral evaluation - problem focused |
27 |
27 |
$403.24 |
| D0220 |
Intraoral - periapical first radiographic image |
14 |
14 |
$122.92 |