| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
4,239 |
4,239 |
$187K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,824 |
1,301 |
$132K |
| D1206 |
Topical application of fluoride varnish |
4,017 |
4,017 |
$124K |
| D0120 |
Periodic oral evaluation - established patient |
3,309 |
3,309 |
$82K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
736 |
559 |
$42K |
| D0272 |
Bitewings - two radiographic images |
3,346 |
3,345 |
$40K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
223 |
168 |
$31K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,205 |
1,084 |
$29K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
851 |
851 |
$22K |
| D1351 |
Sealant - per tooth |
1,059 |
378 |
$21K |
| D0603 |
|
2,065 |
2,065 |
$21K |
| D0220 |
Intraoral - periapical first radiographic image |
2,587 |
2,566 |
$18K |
| D0140 |
Limited oral evaluation - problem focused |
294 |
293 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,797 |
1,792 |
$10K |
| D0330 |
Panoramic radiographic image |
160 |
160 |
$7K |
| D1354 |
|
512 |
187 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
90 |
67 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
203 |
203 |
$2K |
| D1110 |
Prophylaxis - adult |
19 |
19 |
$824.22 |
| D0602 |
|
78 |
78 |
$780.00 |
| D2330 |
|
14 |
12 |
$700.00 |
| D0274 |
Bitewings - four radiographic images |
32 |
32 |
$694.08 |