| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
7,419 |
7,379 |
$301K |
| D0120 |
Periodic oral evaluation - established patient |
4,121 |
4,106 |
$252K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,326 |
810 |
$86K |
| D1206 |
Topical application of fluoride varnish |
4,366 |
4,336 |
$79K |
| D1310 |
|
2,945 |
2,936 |
$64K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
856 |
851 |
$53K |
| D9993 |
|
2,141 |
2,135 |
$43K |
| D1351 |
Sealant - per tooth |
1,558 |
436 |
$40K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,991 |
3,357 |
$28K |
| D0272 |
Bitewings - two radiographic images |
2,123 |
2,116 |
$25K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,532 |
2,519 |
$24K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
310 |
229 |
$16K |
| D0603 |
|
2,477 |
2,448 |
$10K |
| D7140 |
Extraction, erupted tooth or exposed root |
91 |
62 |
$5K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
69 |
48 |
$5K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
106 |
90 |
$4K |
| D9430 |
|
89 |
88 |
$3K |
| D0274 |
Bitewings - four radiographic images |
106 |
106 |
$2K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
17 |
12 |
$2K |
| D0350 |
|
178 |
116 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
42 |
41 |
$504.00 |
| D1999 |
|
40 |
38 |
$70.00 |
| D0601 |
|
88 |
88 |
$0.00 |
| D1330 |
|
2,277 |
2,269 |
$0.00 |
| D0602 |
|
14 |
14 |
$0.00 |