| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
5,576 |
5,463 |
$137K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,378 |
789 |
$96K |
| D1206 |
Topical application of fluoride varnish |
6,200 |
6,075 |
$94K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,384 |
2,186 |
$60K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
777 |
468 |
$60K |
| D0120 |
Periodic oral evaluation - established patient |
4,299 |
4,211 |
$59K |
| D1351 |
Sealant - per tooth |
1,333 |
496 |
$35K |
| D7140 |
Extraction, erupted tooth or exposed root |
710 |
427 |
$30K |
| D0272 |
Bitewings - two radiographic images |
1,834 |
1,793 |
$28K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,082 |
1,054 |
$27K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
437 |
285 |
$26K |
| D0240 |
|
2,711 |
1,338 |
$25K |
| D1110 |
Prophylaxis - adult |
333 |
324 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
1,101 |
1,069 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
741 |
650 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
298 |
286 |
$4K |
| D0330 |
Panoramic radiographic image |
25 |
25 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
109 |
109 |
$2K |
| D0274 |
Bitewings - four radiographic images |
82 |
82 |
$1K |
| D3120 |
|
142 |
88 |
$263.23 |