| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,420 |
2,416 |
$94K |
| D0120 |
Periodic oral evaluation - established patient |
1,810 |
1,809 |
$50K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,290 |
2,286 |
$43K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
313 |
100 |
$31K |
| D0220 |
Intraoral - periapical first radiographic image |
1,786 |
1,745 |
$22K |
| D0272 |
Bitewings - two radiographic images |
1,240 |
1,236 |
$20K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,864 |
1,097 |
$16K |
| D1351 |
Sealant - per tooth |
455 |
95 |
$16K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
429 |
418 |
$11K |
| D7140 |
Extraction, erupted tooth or exposed root |
122 |
67 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
152 |
152 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
139 |
139 |
$5K |
| D9420 |
|
25 |
25 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
45 |
27 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
16 |
13 |
$896.00 |
| D1354 |
|
32 |
12 |
$64.00 |
| D1330 |
|
26 |
26 |
$0.00 |