| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,108 |
3,067 |
$136K |
| D1206 |
Topical application of fluoride varnish |
3,558 |
3,517 |
$128K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
918 |
326 |
$126K |
| D0120 |
Periodic oral evaluation - established patient |
3,237 |
3,200 |
$77K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
886 |
568 |
$68K |
| D7140 |
Extraction, erupted tooth or exposed root |
754 |
365 |
$64K |
| D1351 |
Sealant - per tooth |
1,969 |
647 |
$64K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
397 |
324 |
$42K |
| D0330 |
Panoramic radiographic image |
526 |
526 |
$34K |
| D1110 |
Prophylaxis - adult |
544 |
544 |
$33K |
| D0272 |
Bitewings - two radiographic images |
991 |
991 |
$24K |
| D0274 |
Bitewings - four radiographic images |
688 |
688 |
$23K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
427 |
422 |
$14K |
| D1354 |
|
508 |
204 |
$13K |
| D0140 |
Limited oral evaluation - problem focused |
274 |
270 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
300 |
299 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
563 |
558 |
$8K |
| D9420 |
|
30 |
30 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
105 |
105 |
$3K |
| D0240 |
|
33 |
33 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
18 |
18 |
$270.00 |
| D0270 |
|
13 |
13 |
$195.00 |