| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
7,257 |
7,253 |
$252K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,565 |
826 |
$208K |
| D1206 |
Topical application of fluoride varnish |
8,505 |
8,501 |
$169K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,176 |
318 |
$143K |
| D0120 |
Periodic oral evaluation - established patient |
5,541 |
5,541 |
$134K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,077 |
483 |
$105K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
515 |
271 |
$84K |
| D3120 |
|
2,203 |
417 |
$83K |
| D0272 |
Bitewings - two radiographic images |
2,717 |
2,714 |
$57K |
| D3240 |
|
360 |
133 |
$49K |
| D1351 |
Sealant - per tooth |
1,209 |
385 |
$44K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,302 |
1,265 |
$40K |
| D1110 |
Prophylaxis - adult |
721 |
721 |
$38K |
| D9248 |
|
267 |
265 |
$37K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
673 |
671 |
$27K |
| D0330 |
Panoramic radiographic image |
459 |
459 |
$24K |
| D0145 |
Oral evaluation for a patient under three years of age |
645 |
645 |
$21K |
| D9219 |
|
474 |
471 |
$19K |
| D2330 |
|
158 |
41 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
1,062 |
1,056 |
$13K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
110 |
86 |
$12K |
| D2934 |
|
36 |
12 |
$6K |
| D3230 |
|
36 |
12 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
95 |
93 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
111 |
111 |
$2K |
| D0274 |
Bitewings - four radiographic images |
47 |
47 |
$1K |
| D0240 |
|
13 |
13 |
$463.68 |