| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,215 |
3,005 |
$129K |
| D1206 |
Topical application of fluoride varnish |
3,143 |
2,953 |
$100K |
| D1351 |
Sealant - per tooth |
2,594 |
663 |
$48K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
950 |
233 |
$44K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
977 |
591 |
$40K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,002 |
963 |
$30K |
| D7140 |
Extraction, erupted tooth or exposed root |
916 |
368 |
$26K |
| D0272 |
Bitewings - two radiographic images |
1,554 |
1,410 |
$24K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
697 |
409 |
$22K |
| D0330 |
Panoramic radiographic image |
583 |
541 |
$21K |
| D0120 |
Periodic oral evaluation - established patient |
1,458 |
1,278 |
$20K |
| D0140 |
Limited oral evaluation - problem focused |
617 |
576 |
$19K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,249 |
903 |
$19K |
| D0274 |
Bitewings - four radiographic images |
568 |
505 |
$11K |
| D0603 |
|
2,681 |
2,496 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
760 |
674 |
$7K |
| D0240 |
|
504 |
254 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
143 |
102 |
$6K |
| D9310 |
|
74 |
72 |
$3K |
| D9420 |
|
77 |
70 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
549 |
446 |
$3K |
| D3120 |
|
343 |
209 |
$2K |
| D2330 |
|
13 |
12 |
$676.56 |
| D0270 |
|
30 |
27 |
$235.80 |
| D1330 |
|
2,805 |
2,619 |
$0.00 |