| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,525 |
2,502 |
$80K |
| D1206 |
Topical application of fluoride varnish |
3,227 |
3,123 |
$62K |
| D1351 |
Sealant - per tooth |
1,936 |
637 |
$52K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
972 |
934 |
$47K |
| D0120 |
Periodic oral evaluation - established patient |
2,007 |
1,996 |
$43K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
606 |
380 |
$40K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
312 |
204 |
$31K |
| D7140 |
Extraction, erupted tooth or exposed root |
349 |
220 |
$24K |
| D9920 |
|
173 |
170 |
$24K |
| D0272 |
Bitewings - two radiographic images |
1,133 |
1,122 |
$19K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
242 |
185 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
599 |
587 |
$13K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
85 |
72 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
733 |
721 |
$6K |
| D9110 |
|
178 |
175 |
$6K |
| D0240 |
|
208 |
198 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
258 |
247 |
$4K |
| D0330 |
Panoramic radiographic image |
68 |
67 |
$3K |
| D1110 |
Prophylaxis - adult |
20 |
20 |
$638.73 |