| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
6,191 |
5,964 |
$353K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,529 |
635 |
$176K |
| D1208 |
Topical application of fluoride, excluding varnish |
6,823 |
6,583 |
$110K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,067 |
2,983 |
$96K |
| D0120 |
Periodic oral evaluation - established patient |
4,040 |
3,850 |
$94K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,361 |
717 |
$88K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,094 |
740 |
$72K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,836 |
1,710 |
$67K |
| D0272 |
Bitewings - two radiographic images |
2,750 |
2,663 |
$53K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
948 |
673 |
$50K |
| D1110 |
Prophylaxis - adult |
877 |
842 |
$49K |
| D0140 |
Limited oral evaluation - problem focused |
1,148 |
1,108 |
$42K |
| D0330 |
Panoramic radiographic image |
871 |
854 |
$40K |
| D1351 |
Sealant - per tooth |
1,215 |
315 |
$27K |
| D0274 |
Bitewings - four radiographic images |
731 |
704 |
$23K |
| D0220 |
Intraoral - periapical first radiographic image |
1,360 |
1,314 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
996 |
379 |
$8K |
| D9986 |
|
16 |
12 |
$0.00 |