| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
4,331 |
4,317 |
$187K |
| D1351 |
Sealant - per tooth |
8,417 |
1,982 |
$159K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,247 |
1,106 |
$152K |
| D1206 |
Topical application of fluoride varnish |
4,544 |
4,530 |
$140K |
| D0120 |
Periodic oral evaluation - established patient |
3,787 |
3,779 |
$94K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,708 |
1,653 |
$42K |
| D1353 |
|
4,254 |
999 |
$37K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
569 |
393 |
$30K |
| D0272 |
Bitewings - two radiographic images |
2,101 |
2,099 |
$20K |
| D7140 |
Extraction, erupted tooth or exposed root |
282 |
179 |
$18K |
| D0603 |
|
2,238 |
2,223 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
3,729 |
3,710 |
$16K |
| D0274 |
Bitewings - four radiographic images |
1,092 |
1,086 |
$12K |
| D0140 |
Limited oral evaluation - problem focused |
234 |
233 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
405 |
404 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,416 |
3,405 |
$10K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
75 |
44 |
$8K |
| D1110 |
Prophylaxis - adult |
189 |
188 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
57 |
43 |
$5K |
| D0601 |
|
441 |
441 |
$4K |
| D9920 |
|
64 |
61 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
12 |
12 |
$540.00 |
| D0602 |
|
29 |
29 |
$280.00 |