| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,950 |
3,738 |
$171K |
| D1206 |
Topical application of fluoride varnish |
4,422 |
4,183 |
$159K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,152 |
302 |
$158K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,287 |
598 |
$106K |
| D0120 |
Periodic oral evaluation - established patient |
4,187 |
3,974 |
$99K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,101 |
683 |
$83K |
| D1351 |
Sealant - per tooth |
2,497 |
751 |
$82K |
| D9420 |
|
373 |
339 |
$82K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
595 |
455 |
$62K |
| D1110 |
Prophylaxis - adult |
766 |
706 |
$46K |
| D0330 |
Panoramic radiographic image |
653 |
627 |
$40K |
| D0274 |
Bitewings - four radiographic images |
984 |
904 |
$32K |
| D0272 |
Bitewings - two radiographic images |
1,359 |
1,303 |
$32K |
| D0140 |
Limited oral evaluation - problem focused |
501 |
461 |
$17K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
469 |
431 |
$16K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
416 |
394 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
841 |
806 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
288 |
262 |
$8K |
| D1354 |
|
96 |
31 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
14 |
14 |
$1K |
| D0240 |
|
37 |
37 |
$1K |
| D0145 |
Oral evaluation for a patient under three years of age |
12 |
12 |
$360.00 |
| D9991 |
|
17 |
16 |
$0.00 |