| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
5,871 |
5,813 |
$250K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,840 |
1,057 |
$222K |
| D1206 |
Topical application of fluoride varnish |
7,473 |
7,392 |
$184K |
| D0120 |
Periodic oral evaluation - established patient |
6,111 |
6,043 |
$178K |
| D1351 |
Sealant - per tooth |
4,014 |
939 |
$132K |
| D0140 |
Limited oral evaluation - problem focused |
2,379 |
2,139 |
$104K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
560 |
261 |
$86K |
| D7140 |
Extraction, erupted tooth or exposed root |
684 |
363 |
$71K |
| D9248 |
|
216 |
198 |
$40K |
| D0272 |
Bitewings - two radiographic images |
2,574 |
2,540 |
$39K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,022 |
1,810 |
$37K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
390 |
252 |
$36K |
| D1110 |
Prophylaxis - adult |
502 |
490 |
$29K |
| D3120 |
|
607 |
306 |
$21K |
| D1330 |
|
3,422 |
3,379 |
$21K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
377 |
374 |
$19K |
| D0330 |
Panoramic radiographic image |
359 |
353 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
496 |
473 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
19 |
12 |
$3K |
| D4355 |
|
26 |
26 |
$3K |
| D0274 |
Bitewings - four radiographic images |
89 |
89 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
116 |
109 |
$1K |
| D0240 |
|
58 |
55 |
$585.00 |