| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,943 |
2,915 |
$159K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,535 |
662 |
$82K |
| D9248 |
|
452 |
432 |
$40K |
| D0120 |
Periodic oral evaluation - established patient |
1,261 |
1,257 |
$38K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
908 |
414 |
$38K |
| D0272 |
Bitewings - two radiographic images |
1,749 |
1,728 |
$36K |
| D0140 |
Limited oral evaluation - problem focused |
1,006 |
1,001 |
$33K |
| D0220 |
Intraoral - periapical first radiographic image |
1,991 |
1,944 |
$31K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,451 |
2,691 |
$31K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,529 |
2,504 |
$25K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
806 |
790 |
$25K |
| D1351 |
Sealant - per tooth |
1,023 |
228 |
$23K |
| D7140 |
Extraction, erupted tooth or exposed root |
355 |
176 |
$13K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
602 |
583 |
$11K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
97 |
42 |
$9K |
| D1206 |
Topical application of fluoride varnish |
314 |
314 |
$6K |
| D0274 |
Bitewings - four radiographic images |
178 |
175 |
$4K |
| D0330 |
Panoramic radiographic image |
84 |
84 |
$3K |
| D2330 |
|
42 |
25 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
34 |
26 |
$2K |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$597.72 |
| D3120 |
|
23 |
14 |
$430.50 |