| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,392 |
2,385 |
$92K |
| D0120 |
Periodic oral evaluation - established patient |
2,451 |
2,448 |
$67K |
| D1206 |
Topical application of fluoride varnish |
2,736 |
2,729 |
$50K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
486 |
132 |
$45K |
| D1351 |
Sealant - per tooth |
1,348 |
459 |
$45K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
743 |
474 |
$40K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
391 |
290 |
$26K |
| D0272 |
Bitewings - two radiographic images |
1,135 |
1,129 |
$20K |
| D0330 |
Panoramic radiographic image |
424 |
424 |
$19K |
| D1110 |
Prophylaxis - adult |
397 |
396 |
$18K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
618 |
566 |
$16K |
| D0603 |
|
1,471 |
1,467 |
$9K |
| D7140 |
Extraction, erupted tooth or exposed root |
103 |
57 |
$8K |
| D0240 |
|
551 |
310 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
445 |
422 |
$5K |
| D0602 |
|
843 |
842 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
132 |
130 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
109 |
109 |
$4K |
| D0274 |
Bitewings - four radiographic images |
144 |
144 |
$4K |
| D0601 |
|
364 |
361 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
260 |
132 |
$2K |
| D3120 |
|
301 |
187 |
$56.00 |