| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,011 |
1,930 |
$99K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
874 |
319 |
$96K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
881 |
485 |
$55K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
800 |
424 |
$38K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,042 |
798 |
$35K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,079 |
1,014 |
$28K |
| D1206 |
Topical application of fluoride varnish |
1,653 |
1,581 |
$24K |
| D0120 |
Periodic oral evaluation - established patient |
1,023 |
999 |
$22K |
| D0272 |
Bitewings - two radiographic images |
1,084 |
1,016 |
$17K |
| D7140 |
Extraction, erupted tooth or exposed root |
305 |
175 |
$14K |
| D0330 |
Panoramic radiographic image |
307 |
287 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
920 |
843 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
371 |
371 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
726 |
378 |
$4K |
| D1351 |
Sealant - per tooth |
183 |
78 |
$3K |
| D1330 |
|
677 |
609 |
$3K |
| D3120 |
|
198 |
99 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
26 |
25 |
$833.25 |
| D1999 |
|
14 |
12 |
$0.00 |