| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
4,382 |
4,382 |
$214K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,065 |
747 |
$147K |
| D1351 |
Sealant - per tooth |
3,679 |
946 |
$147K |
| D0120 |
Periodic oral evaluation - established patient |
3,917 |
3,917 |
$125K |
| D1206 |
Topical application of fluoride varnish |
4,478 |
4,478 |
$118K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
276 |
226 |
$49K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,434 |
1,310 |
$28K |
| D0272 |
Bitewings - two radiographic images |
1,702 |
1,702 |
$28K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
484 |
484 |
$27K |
| D0140 |
Limited oral evaluation - problem focused |
472 |
461 |
$22K |
| D1330 |
|
2,539 |
2,539 |
$18K |
| D7140 |
Extraction, erupted tooth or exposed root |
113 |
89 |
$15K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
85 |
82 |
$15K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
122 |
102 |
$13K |
| D3120 |
|
243 |
191 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
74 |
72 |
$874.68 |
| D0240 |
|
70 |
70 |
$648.00 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$288.84 |