| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
6,227 |
6,153 |
$133K |
| D1206 |
Topical application of fluoride varnish |
7,455 |
7,330 |
$95K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,578 |
1,497 |
$61K |
| D0160 |
|
957 |
953 |
$52K |
| D0120 |
Periodic oral evaluation - established patient |
3,221 |
3,192 |
$50K |
| D0272 |
Bitewings - two radiographic images |
3,141 |
3,096 |
$42K |
| D1351 |
Sealant - per tooth |
1,595 |
298 |
$27K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
770 |
767 |
$16K |
| D0210 |
Intraoral - complete series of radiographic images |
327 |
321 |
$15K |
| D0191 |
|
1,280 |
1,188 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
159 |
99 |
$9K |
| D1110 |
Prophylaxis - adult |
281 |
280 |
$8K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
44 |
30 |
$4K |
| D1354 |
|
444 |
107 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
38 |
27 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
24 |
12 |
$1K |
| D0240 |
|
86 |
44 |
$970.48 |
| D9910 |
|
40 |
12 |
$609.86 |
| D0274 |
Bitewings - four radiographic images |
32 |
32 |
$596.47 |
| D0140 |
Limited oral evaluation - problem focused |
26 |
25 |
$519.50 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$444.95 |
| D1999 |
|
26 |
26 |
$0.00 |
| D0603 |
|
177 |
176 |
$0.00 |
| D1310 |
|
177 |
176 |
$0.00 |