| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,143 |
1,139 |
$50K |
| D1206 |
Topical application of fluoride varnish |
1,214 |
1,213 |
$38K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
497 |
251 |
$35K |
| D1351 |
Sealant - per tooth |
1,693 |
446 |
$33K |
| D0120 |
Periodic oral evaluation - established patient |
1,079 |
1,079 |
$27K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
532 |
517 |
$13K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
212 |
128 |
$12K |
| D0272 |
Bitewings - two radiographic images |
551 |
550 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
58 |
37 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
884 |
883 |
$4K |
| D9920 |
|
172 |
169 |
$4K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
41 |
27 |
$4K |
| D0603 |
|
374 |
374 |
$3K |
| D1353 |
|
304 |
78 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
807 |
794 |
$3K |
| D0274 |
Bitewings - four radiographic images |
200 |
200 |
$2K |
| D1110 |
Prophylaxis - adult |
77 |
77 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
42 |
42 |
$1K |
| D0601 |
|
19 |
19 |
$140.00 |
| D0602 |
|
13 |
13 |
$120.00 |