| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,489 |
3,436 |
$44K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,354 |
4,293 |
$26K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,137 |
1,688 |
$22K |
| D0120 |
Periodic oral evaluation - established patient |
2,738 |
2,705 |
$20K |
| D0220 |
Intraoral - periapical first radiographic image |
2,253 |
2,179 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
643 |
625 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
246 |
117 |
$8K |
| D0330 |
Panoramic radiographic image |
214 |
212 |
$3K |
| D9248 |
|
139 |
135 |
$3K |
| D0274 |
Bitewings - four radiographic images |
415 |
405 |
$3K |
| D0272 |
Bitewings - two radiographic images |
537 |
531 |
$2K |
| D1999 |
|
1,458 |
1,379 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
59 |
36 |
$1K |
| D1354 |
|
258 |
78 |
$842.05 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
96 |
87 |
$698.83 |
| D1110 |
Prophylaxis - adult |
109 |
109 |
$697.04 |
| D1351 |
Sealant - per tooth |
135 |
47 |
$562.55 |
| D0140 |
Limited oral evaluation - problem focused |
148 |
144 |
$551.94 |
| D7140 |
Extraction, erupted tooth or exposed root |
19 |
12 |
$513.26 |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
23 |
14 |
$465.52 |
| D0602 |
|
51 |
51 |
$0.00 |