| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
5,109 |
5,109 |
$230K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,306 |
1,641 |
$213K |
| D1206 |
Topical application of fluoride varnish |
4,959 |
4,959 |
$155K |
| D0120 |
Periodic oral evaluation - established patient |
4,392 |
4,392 |
$122K |
| D0272 |
Bitewings - two radiographic images |
4,256 |
4,256 |
$92K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
506 |
430 |
$88K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,116 |
921 |
$86K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,950 |
1,865 |
$47K |
| D0220 |
Intraoral - periapical first radiographic image |
3,847 |
3,801 |
$40K |
| D1351 |
Sealant - per tooth |
1,040 |
360 |
$30K |
| D0603 |
|
2,761 |
2,761 |
$27K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,312 |
2,309 |
$23K |
| D1354 |
|
1,730 |
661 |
$17K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
382 |
382 |
$17K |
| D7140 |
Extraction, erupted tooth or exposed root |
97 |
82 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
123 |
122 |
$5K |
| D0330 |
Panoramic radiographic image |
29 |
29 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
13 |
13 |
$585.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$300.00 |