| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,272 |
3,094 |
$147K |
| D1206 |
Topical application of fluoride varnish |
2,239 |
2,128 |
$93K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,680 |
881 |
$67K |
| D1351 |
Sealant - per tooth |
2,711 |
446 |
$48K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,777 |
1,677 |
$48K |
| D0272 |
Bitewings - two radiographic images |
2,152 |
2,027 |
$36K |
| D0120 |
Periodic oral evaluation - established patient |
1,847 |
1,706 |
$30K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,648 |
3,234 |
$24K |
| D0220 |
Intraoral - periapical first radiographic image |
2,728 |
2,547 |
$24K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,505 |
1,263 |
$21K |
| D0274 |
Bitewings - four radiographic images |
905 |
860 |
$19K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
364 |
259 |
$16K |
| D0330 |
Panoramic radiographic image |
338 |
325 |
$12K |
| D7140 |
Extraction, erupted tooth or exposed root |
503 |
280 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,031 |
963 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
296 |
209 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
257 |
246 |
$7K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
37 |
29 |
$2K |
| D7111 |
|
17 |
14 |
$527.00 |