| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,529 |
3,527 |
$128K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
754 |
400 |
$95K |
| D1206 |
Topical application of fluoride varnish |
4,373 |
4,372 |
$91K |
| D0120 |
Periodic oral evaluation - established patient |
3,390 |
3,390 |
$86K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,068 |
1,068 |
$43K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,154 |
2,147 |
$41K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
381 |
236 |
$39K |
| D1110 |
Prophylaxis - adult |
711 |
711 |
$39K |
| D0220 |
Intraoral - periapical first radiographic image |
2,654 |
2,635 |
$35K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,072 |
984 |
$34K |
| D1351 |
Sealant - per tooth |
657 |
198 |
$23K |
| D0272 |
Bitewings - two radiographic images |
946 |
946 |
$20K |
| D0274 |
Bitewings - four radiographic images |
481 |
481 |
$15K |
| D0350 |
|
399 |
398 |
$13K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
57 |
25 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
65 |
38 |
$6K |
| D0330 |
Panoramic radiographic image |
93 |
93 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
253 |
250 |
$4K |
| D0240 |
|
113 |
111 |
$4K |
| D8670 |
Periodic orthodontic treatment visit |
12 |
12 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
31 |
30 |
$1K |