| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,697 |
3,692 |
$162K |
| D1206 |
Topical application of fluoride varnish |
3,887 |
3,876 |
$120K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,619 |
824 |
$111K |
| D1351 |
Sealant - per tooth |
4,910 |
1,290 |
$95K |
| D0120 |
Periodic oral evaluation - established patient |
3,268 |
3,262 |
$81K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
886 |
565 |
$48K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,495 |
1,457 |
$37K |
| D7140 |
Extraction, erupted tooth or exposed root |
480 |
289 |
$29K |
| D1353 |
|
2,909 |
647 |
$25K |
| D0272 |
Bitewings - two radiographic images |
1,968 |
1,965 |
$19K |
| D0603 |
|
2,209 |
2,200 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
3,073 |
3,060 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,901 |
2,884 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
379 |
376 |
$9K |
| D0274 |
Bitewings - four radiographic images |
598 |
595 |
$7K |
| D9920 |
|
272 |
269 |
$7K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
68 |
52 |
$7K |
| D1110 |
Prophylaxis - adult |
199 |
198 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
116 |
115 |
$5K |
| D0145 |
Oral evaluation for a patient under three years of age |
83 |
83 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
36 |
30 |
$3K |
| D0601 |
|
71 |
71 |
$610.00 |