| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,388 |
1,337 |
$58K |
| D1206 |
Topical application of fluoride varnish |
1,335 |
1,293 |
$44K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
148 |
28 |
$7K |
| D0272 |
Bitewings - two radiographic images |
430 |
404 |
$7K |
| D1351 |
Sealant - per tooth |
309 |
62 |
$7K |
| D0330 |
Panoramic radiographic image |
169 |
164 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
152 |
150 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
136 |
43 |
$4K |
| D0274 |
Bitewings - four radiographic images |
140 |
131 |
$3K |
| D0240 |
|
214 |
110 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
64 |
40 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
66 |
33 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
114 |
106 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
70 |
61 |
$1K |
| D9420 |
|
42 |
31 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
49 |
42 |
$775.00 |
| D0603 |
|
237 |
226 |
$730.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
88 |
83 |
$482.98 |
| D1208 |
Topical application of fluoride, excluding varnish |
55 |
49 |
$450.56 |
| D1330 |
|
601 |
575 |
$0.00 |