| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,834 |
1,615 |
$84K |
| D1206 |
Topical application of fluoride varnish |
1,385 |
1,202 |
$61K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
729 |
344 |
$27K |
| D1351 |
Sealant - per tooth |
1,572 |
359 |
$26K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
341 |
124 |
$24K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
793 |
733 |
$22K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
577 |
327 |
$19K |
| D0120 |
Periodic oral evaluation - established patient |
902 |
770 |
$18K |
| D0272 |
Bitewings - two radiographic images |
765 |
686 |
$13K |
| D7140 |
Extraction, erupted tooth or exposed root |
310 |
135 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
758 |
656 |
$9K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
642 |
511 |
$9K |
| D0330 |
Panoramic radiographic image |
253 |
223 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
310 |
282 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,690 |
756 |
$8K |
| D0274 |
Bitewings - four radiographic images |
267 |
224 |
$5K |
| D0145 |
Oral evaluation for a patient under three years of age |
208 |
186 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
398 |
372 |
$3K |
| D0170 |
|
108 |
85 |
$1K |
| D0270 |
|
30 |
25 |
$259.38 |
| D3120 |
|
107 |
72 |
$225.50 |
| D1330 |
|
12 |
12 |
$0.00 |