| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,142 |
1,917 |
$84K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
746 |
414 |
$34K |
| D1351 |
Sealant - per tooth |
1,652 |
382 |
$34K |
| D1206 |
Topical application of fluoride varnish |
1,068 |
946 |
$33K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,125 |
995 |
$31K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
376 |
114 |
$23K |
| D0120 |
Periodic oral evaluation - established patient |
795 |
726 |
$17K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
474 |
276 |
$16K |
| D0272 |
Bitewings - two radiographic images |
978 |
869 |
$15K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
911 |
715 |
$15K |
| D0240 |
|
963 |
481 |
$12K |
| D0274 |
Bitewings - four radiographic images |
450 |
408 |
$9K |
| D0330 |
Panoramic radiographic image |
265 |
241 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
941 |
850 |
$9K |
| D7140 |
Extraction, erupted tooth or exposed root |
190 |
79 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
511 |
445 |
$5K |
| D0603 |
|
1,378 |
1,201 |
$5K |
| D9420 |
|
105 |
91 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
457 |
383 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
64 |
48 |
$2K |
| D8660 |
|
30 |
27 |
$1K |
| D1999 |
|
72 |
72 |
$1K |
| D9999 |
Unspecified adjunctive procedure, by report |
65 |
65 |
$650.00 |
| D1353 |
|
32 |
16 |
$377.20 |
| D9995 |
|
61 |
33 |
$310.00 |
| D1330 |
|
435 |
328 |
$0.00 |