| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,314 |
2,591 |
$81K |
| D0120 |
Periodic oral evaluation - established patient |
3,023 |
2,380 |
$67K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
692 |
242 |
$59K |
| D1206 |
Topical application of fluoride varnish |
1,554 |
1,380 |
$31K |
| D0272 |
Bitewings - two radiographic images |
1,773 |
1,405 |
$29K |
| D0330 |
Panoramic radiographic image |
623 |
471 |
$27K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,040 |
698 |
$11K |
| D0140 |
Limited oral evaluation - problem focused |
368 |
247 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
293 |
205 |
$9K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,004 |
771 |
$9K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
61 |
25 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
131 |
48 |
$7K |
| D1351 |
Sealant - per tooth |
277 |
54 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
35 |
14 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
234 |
112 |
$1K |
| D1110 |
Prophylaxis - adult |
13 |
12 |
$527.49 |
| D9248 |
|
164 |
126 |
$171.33 |
| D0230 |
Intraoral - periapical each additional radiographic image |
23 |
14 |
$168.33 |