| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
4,912 |
4,544 |
$122K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,095 |
640 |
$106K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,392 |
2,342 |
$80K |
| D1206 |
Topical application of fluoride varnish |
3,225 |
3,070 |
$71K |
| D1351 |
Sealant - per tooth |
2,700 |
426 |
$61K |
| D0330 |
Panoramic radiographic image |
1,192 |
1,130 |
$49K |
| D0120 |
Periodic oral evaluation - established patient |
2,325 |
1,931 |
$49K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,436 |
1,352 |
$43K |
| D0272 |
Bitewings - two radiographic images |
2,263 |
2,052 |
$38K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
493 |
302 |
$31K |
| D0274 |
Bitewings - four radiographic images |
1,194 |
1,116 |
$31K |
| D7140 |
Extraction, erupted tooth or exposed root |
418 |
240 |
$31K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,752 |
1,533 |
$23K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
80 |
50 |
$11K |
| D0210 |
Intraoral - complete series of radiographic images |
115 |
114 |
$8K |
| D0145 |
Oral evaluation for a patient under three years of age |
159 |
158 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
137 |
127 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
316 |
293 |
$3K |
| D9248 |
|
33 |
31 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
12 |
12 |
$136.40 |
| D0603 |
|
1,363 |
1,184 |
$0.00 |