| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
6,320 |
5,717 |
$190K |
| D1206 |
Topical application of fluoride varnish |
6,545 |
5,885 |
$121K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,598 |
987 |
$104K |
| D0120 |
Periodic oral evaluation - established patient |
3,937 |
3,576 |
$85K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,961 |
2,553 |
$74K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,038 |
1,915 |
$55K |
| D1351 |
Sealant - per tooth |
2,245 |
870 |
$52K |
| D0272 |
Bitewings - two radiographic images |
1,820 |
1,632 |
$27K |
| D0220 |
Intraoral - periapical first radiographic image |
2,418 |
2,155 |
$26K |
| D0330 |
Panoramic radiographic image |
638 |
553 |
$21K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,929 |
884 |
$16K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
268 |
180 |
$13K |
| D7140 |
Extraction, erupted tooth or exposed root |
245 |
128 |
$9K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
62 |
43 |
$7K |
| D0274 |
Bitewings - four radiographic images |
387 |
312 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
187 |
155 |
$3K |
| D7961 |
|
20 |
12 |
$3K |
| D1110 |
Prophylaxis - adult |
73 |
54 |
$2K |
| D1354 |
|
49 |
15 |
$233.20 |
| D1330 |
|
5,874 |
5,253 |
$0.00 |
| D1999 |
|
57 |
54 |
$0.00 |