| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
5,695 |
5,695 |
$171K |
| D1351 |
Sealant - per tooth |
6,164 |
1,463 |
$111K |
| D0120 |
Periodic oral evaluation - established patient |
4,551 |
4,549 |
$109K |
| D1206 |
Topical application of fluoride varnish |
5,849 |
5,834 |
$105K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,782 |
1,105 |
$85K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,108 |
1,835 |
$37K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
846 |
607 |
$35K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,334 |
1,334 |
$32K |
| D7140 |
Extraction, erupted tooth or exposed root |
578 |
413 |
$28K |
| D0603 |
|
2,496 |
2,496 |
$25K |
| D0272 |
Bitewings - two radiographic images |
2,681 |
2,678 |
$23K |
| D0220 |
Intraoral - periapical first radiographic image |
3,098 |
3,061 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,117 |
2,111 |
$12K |
| D0210 |
Intraoral - complete series of radiographic images |
303 |
303 |
$11K |
| D0601 |
|
1,025 |
1,025 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
361 |
356 |
$9K |
| D0274 |
Bitewings - four radiographic images |
459 |
459 |
$7K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
36 |
25 |
$4K |
| D0602 |
|
329 |
329 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
55 |
49 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
43 |
43 |
$516.00 |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$288.00 |
| D1354 |
|
36 |
12 |
$180.00 |
| D1999 |
|
1,308 |
1,259 |
$0.00 |