| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
5,565 |
5,564 |
$302K |
| D0120 |
Periodic oral evaluation - established patient |
5,146 |
5,145 |
$170K |
| D1351 |
Sealant - per tooth |
6,395 |
1,445 |
$153K |
| D1206 |
Topical application of fluoride varnish |
4,053 |
4,051 |
$124K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,385 |
856 |
$95K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
554 |
198 |
$75K |
| D0272 |
Bitewings - two radiographic images |
4,198 |
4,198 |
$53K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,808 |
1,808 |
$52K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
372 |
300 |
$39K |
| D0240 |
|
2,993 |
2,992 |
$38K |
| D0603 |
|
3,296 |
3,294 |
$27K |
| D0220 |
Intraoral - periapical first radiographic image |
2,028 |
2,025 |
$14K |
| D0140 |
Limited oral evaluation - problem focused |
395 |
393 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
374 |
374 |
$12K |
| D9920 |
|
473 |
458 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,719 |
1,716 |
$8K |
| D9999 |
Unspecified adjunctive procedure, by report |
12 |
12 |
$8K |
| D1110 |
Prophylaxis - adult |
140 |
140 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
121 |
101 |
$7K |
| D0274 |
Bitewings - four radiographic images |
460 |
457 |
$7K |
| D0602 |
|
376 |
376 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
45 |
28 |
$3K |
| D0330 |
Panoramic radiographic image |
40 |
40 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
32 |
31 |
$837.00 |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$672.00 |