| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,583 |
1,581 |
$47K |
| D0120 |
Periodic oral evaluation - established patient |
1,830 |
1,827 |
$46K |
| D1206 |
Topical application of fluoride varnish |
2,424 |
2,419 |
$43K |
| D1351 |
Sealant - per tooth |
1,748 |
307 |
$42K |
| D7140 |
Extraction, erupted tooth or exposed root |
392 |
233 |
$24K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
400 |
277 |
$23K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
407 |
301 |
$20K |
| D1110 |
Prophylaxis - adult |
494 |
493 |
$18K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
504 |
501 |
$17K |
| D0272 |
Bitewings - two radiographic images |
909 |
906 |
$15K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
112 |
44 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
363 |
363 |
$10K |
| D0330 |
Panoramic radiographic image |
238 |
238 |
$9K |
| D1330 |
|
1,246 |
1,245 |
$6K |
| D0603 |
|
595 |
595 |
$6K |
| D9248 |
|
32 |
32 |
$6K |
| D0602 |
|
513 |
512 |
$5K |
| D9920 |
|
20 |
20 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
49 |
49 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
239 |
239 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
82 |
79 |
$754.92 |
| D0274 |
Bitewings - four radiographic images |
24 |
24 |
$677.60 |
| D0601 |
|
41 |
41 |
$410.00 |
| D1999 |
|
12 |
12 |
$0.00 |
| D9420 |
|
17 |
17 |
$0.00 |