| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,017 |
1,996 |
$74K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
509 |
333 |
$63K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
265 |
159 |
$61K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
824 |
821 |
$49K |
| D0120 |
Periodic oral evaluation - established patient |
1,715 |
1,698 |
$47K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
445 |
333 |
$42K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,018 |
2,004 |
$40K |
| D0272 |
Bitewings - two radiographic images |
1,189 |
1,183 |
$37K |
| D0330 |
Panoramic radiographic image |
594 |
594 |
$34K |
| D0274 |
Bitewings - four radiographic images |
815 |
810 |
$30K |
| D1351 |
Sealant - per tooth |
953 |
293 |
$29K |
| D1110 |
Prophylaxis - adult |
410 |
409 |
$25K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
449 |
412 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
991 |
984 |
$16K |
| D1206 |
Topical application of fluoride varnish |
452 |
448 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
719 |
712 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
89 |
89 |
$4K |
| D0270 |
|
14 |
14 |
$211.61 |