| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,282 |
1,279 |
$53K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
301 |
167 |
$32K |
| D1206 |
Topical application of fluoride varnish |
1,317 |
1,312 |
$27K |
| D0120 |
Periodic oral evaluation - established patient |
780 |
777 |
$22K |
| D0272 |
Bitewings - two radiographic images |
902 |
896 |
$22K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
478 |
476 |
$22K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
90 |
69 |
$13K |
| D1351 |
Sealant - per tooth |
356 |
124 |
$13K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
298 |
283 |
$12K |
| D0330 |
Panoramic radiographic image |
151 |
150 |
$10K |
| D7140 |
Extraction, erupted tooth or exposed root |
83 |
54 |
$9K |
| D9920 |
|
146 |
144 |
$9K |
| D0240 |
|
308 |
198 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
51 |
45 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
175 |
172 |
$3K |
| D1330 |
|
832 |
828 |
$3K |
| D0601 |
|
355 |
351 |
$3K |
| D0603 |
|
368 |
368 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
208 |
192 |
$2K |
| D1310 |
|
289 |
287 |
$2K |
| D0602 |
|
49 |
49 |
$490.00 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$455.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
22 |
22 |
$396.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
20 |
18 |
$218.00 |
| D1999 |
|
239 |
226 |
$0.00 |