| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
6,534 |
3,839 |
$118K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
884 |
245 |
$79K |
| D1206 |
Topical application of fluoride varnish |
7,209 |
4,229 |
$79K |
| D0120 |
Periodic oral evaluation - established patient |
3,391 |
2,347 |
$54K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,555 |
1,754 |
$50K |
| D7140 |
Extraction, erupted tooth or exposed root |
786 |
283 |
$37K |
| D1351 |
Sealant - per tooth |
1,705 |
355 |
$31K |
| D0272 |
Bitewings - two radiographic images |
3,185 |
1,795 |
$27K |
| D0330 |
Panoramic radiographic image |
1,006 |
572 |
$18K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
485 |
413 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
1,307 |
887 |
$11K |
| D1110 |
Prophylaxis - adult |
310 |
247 |
$10K |
| D1354 |
|
1,937 |
392 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
303 |
276 |
$6K |
| D9248 |
|
64 |
54 |
$5K |
| D1510 |
|
21 |
13 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
38 |
26 |
$2K |
| D0274 |
Bitewings - four radiographic images |
89 |
75 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
103 |
45 |
$817.56 |