| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,035 |
3,035 |
$170K |
| D1351 |
Sealant - per tooth |
4,488 |
1,103 |
$112K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,470 |
1,031 |
$104K |
| D0120 |
Periodic oral evaluation - established patient |
2,735 |
2,735 |
$93K |
| D1206 |
Topical application of fluoride varnish |
2,386 |
2,386 |
$74K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
382 |
272 |
$52K |
| D0272 |
Bitewings - two radiographic images |
2,499 |
2,499 |
$32K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
289 |
253 |
$30K |
| D0240 |
|
2,148 |
2,147 |
$28K |
| D1208 |
Topical application of fluoride, excluding varnish |
791 |
791 |
$25K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
284 |
233 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
483 |
483 |
$16K |
| D0603 |
|
1,596 |
1,596 |
$16K |
| D9920 |
|
495 |
468 |
$14K |
| D7140 |
Extraction, erupted tooth or exposed root |
197 |
167 |
$12K |
| D0170 |
|
222 |
218 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
703 |
703 |
$5K |
| D2332 |
|
49 |
31 |
$5K |
| D0330 |
Panoramic radiographic image |
83 |
83 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
123 |
122 |
$4K |
| D1110 |
Prophylaxis - adult |
45 |
45 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
403 |
403 |
$2K |
| D0274 |
Bitewings - four radiographic images |
129 |
129 |
$2K |
| D0602 |
|
147 |
147 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
37 |
32 |
$984.00 |
| D0601 |
|
44 |
44 |
$440.00 |
| D9430 |
|
16 |
16 |
$252.00 |