| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
6,036 |
5,947 |
$262K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,534 |
802 |
$183K |
| D0120 |
Periodic oral evaluation - established patient |
5,424 |
5,351 |
$160K |
| D1206 |
Topical application of fluoride varnish |
6,191 |
6,105 |
$153K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
820 |
801 |
$42K |
| D0272 |
Bitewings - two radiographic images |
2,644 |
2,607 |
$41K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
228 |
118 |
$35K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,898 |
1,724 |
$35K |
| D1351 |
Sealant - per tooth |
550 |
188 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
902 |
872 |
$9K |
| D7140 |
Extraction, erupted tooth or exposed root |
77 |
52 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
175 |
170 |
$7K |
| D0330 |
Panoramic radiographic image |
71 |
70 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
145 |
141 |
$2K |
| D1110 |
Prophylaxis - adult |
28 |
28 |
$2K |
| D1330 |
|
268 |
266 |
$2K |
| D0274 |
Bitewings - four radiographic images |
25 |
25 |
$528.00 |
| D0240 |
|
15 |
12 |
$117.00 |