| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,701 |
2,490 |
$117K |
| D1206 |
Topical application of fluoride varnish |
3,038 |
2,792 |
$109K |
| D0120 |
Periodic oral evaluation - established patient |
2,823 |
2,606 |
$66K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
439 |
112 |
$60K |
| D7140 |
Extraction, erupted tooth or exposed root |
671 |
283 |
$57K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
594 |
395 |
$45K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
431 |
321 |
$45K |
| D1351 |
Sealant - per tooth |
1,332 |
421 |
$44K |
| D1110 |
Prophylaxis - adult |
495 |
458 |
$30K |
| D0272 |
Bitewings - two radiographic images |
971 |
892 |
$23K |
| D9420 |
|
90 |
72 |
$20K |
| D0274 |
Bitewings - four radiographic images |
557 |
509 |
$19K |
| D0330 |
Panoramic radiographic image |
197 |
179 |
$12K |
| D0140 |
Limited oral evaluation - problem focused |
267 |
231 |
$10K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
285 |
250 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
225 |
205 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
397 |
351 |
$6K |
| D2335 |
|
40 |
13 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
153 |
151 |
$4K |
| D0240 |
|
112 |
96 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
37 |
27 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
50 |
36 |
$867.00 |