| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,321 |
1,320 |
$70K |
| D1351 |
Sealant - per tooth |
2,036 |
427 |
$48K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
701 |
332 |
$47K |
| D1206 |
Topical application of fluoride varnish |
1,368 |
1,367 |
$42K |
| D0120 |
Periodic oral evaluation - established patient |
1,161 |
1,160 |
$39K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
158 |
85 |
$16K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
119 |
63 |
$16K |
| D0272 |
Bitewings - two radiographic images |
713 |
712 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
1,169 |
1,168 |
$8K |
| D0603 |
|
1,300 |
1,292 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
100 |
70 |
$6K |
| D0274 |
Bitewings - four radiographic images |
377 |
376 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,019 |
1,017 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
149 |
146 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
109 |
108 |
$4K |
| D2332 |
|
29 |
14 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
61 |
58 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
21 |
12 |
$1K |
| D1110 |
Prophylaxis - adult |
14 |
14 |
$784.00 |
| D9920 |
|
14 |
14 |
$445.00 |