| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,766 |
1,688 |
$57K |
| D1351 |
Sealant - per tooth |
1,811 |
284 |
$48K |
| D1206 |
Topical application of fluoride varnish |
2,176 |
2,071 |
$40K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
446 |
162 |
$33K |
| D0240 |
|
1,438 |
1,158 |
$26K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
767 |
727 |
$24K |
| D0120 |
Periodic oral evaluation - established patient |
883 |
854 |
$20K |
| D0272 |
Bitewings - two radiographic images |
716 |
690 |
$16K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
92 |
26 |
$11K |
| D7140 |
Extraction, erupted tooth or exposed root |
121 |
53 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
125 |
69 |
$9K |
| D1110 |
Prophylaxis - adult |
107 |
105 |
$5K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
93 |
87 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
220 |
201 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
210 |
64 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
27 |
27 |
$839.97 |
| D0274 |
Bitewings - four radiographic images |
26 |
26 |
$837.75 |
| D0330 |
Panoramic radiographic image |
16 |
15 |
$700.88 |