| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,239 |
2,228 |
$79K |
| D0120 |
Periodic oral evaluation - established patient |
2,046 |
2,037 |
$49K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,414 |
2,404 |
$29K |
| D1351 |
Sealant - per tooth |
553 |
222 |
$21K |
| D0272 |
Bitewings - two radiographic images |
1,481 |
1,466 |
$19K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
254 |
208 |
$16K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
103 |
81 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
866 |
844 |
$10K |
| D7140 |
Extraction, erupted tooth or exposed root |
176 |
126 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
292 |
292 |
$7K |
| D0330 |
Panoramic radiographic image |
216 |
214 |
$6K |
| D1110 |
Prophylaxis - adult |
126 |
126 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
449 |
448 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
59 |
44 |
$2K |
| D1206 |
Topical application of fluoride varnish |
61 |
61 |
$1K |
| D0274 |
Bitewings - four radiographic images |
52 |
52 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
40 |
40 |
$570.22 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
14 |
13 |
$0.00 |
| D1330 |
|
14 |
14 |
$0.00 |