| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,887 |
3,806 |
$108K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
906 |
390 |
$102K |
| D0120 |
Periodic oral evaluation - established patient |
2,988 |
2,951 |
$79K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
467 |
108 |
$68K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,277 |
1,229 |
$58K |
| D1351 |
Sealant - per tooth |
2,006 |
513 |
$57K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,109 |
985 |
$51K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
595 |
264 |
$49K |
| D1206 |
Topical application of fluoride varnish |
2,676 |
2,623 |
$44K |
| D0220 |
Intraoral - periapical first radiographic image |
2,511 |
2,424 |
$38K |
| D0272 |
Bitewings - two radiographic images |
1,802 |
1,758 |
$32K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,276 |
2,163 |
$28K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,483 |
1,446 |
$26K |
| D7140 |
Extraction, erupted tooth or exposed root |
293 |
105 |
$19K |
| D0330 |
Panoramic radiographic image |
308 |
300 |
$15K |
| D9420 |
|
54 |
53 |
$7K |
| D1110 |
Prophylaxis - adult |
131 |
128 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
65 |
61 |
$2K |
| D0274 |
Bitewings - four radiographic images |
26 |
25 |
$671.00 |