| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
7,013 |
6,913 |
$66K |
| D1208 |
Topical application of fluoride, excluding varnish |
8,452 |
8,329 |
$38K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,605 |
730 |
$34K |
| D0120 |
Periodic oral evaluation - established patient |
5,386 |
5,307 |
$29K |
| D0230 |
Intraoral - periapical each additional radiographic image |
7,514 |
3,769 |
$25K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,985 |
1,957 |
$20K |
| D0220 |
Intraoral - periapical first radiographic image |
4,724 |
4,616 |
$15K |
| D0272 |
Bitewings - two radiographic images |
1,862 |
1,838 |
$7K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
181 |
99 |
$7K |
| D0274 |
Bitewings - four radiographic images |
1,088 |
1,075 |
$7K |
| D0330 |
Panoramic radiographic image |
711 |
694 |
$5K |
| D9248 |
|
239 |
231 |
$4K |
| D1110 |
Prophylaxis - adult |
358 |
351 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
258 |
133 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
399 |
381 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
212 |
208 |
$1K |
| D1351 |
Sealant - per tooth |
97 |
33 |
$556.82 |
| D7140 |
Extraction, erupted tooth or exposed root |
17 |
12 |
$452.04 |
| D1999 |
|
2,367 |
2,318 |
$411.51 |
| D1206 |
Topical application of fluoride varnish |
17 |
17 |
$58.41 |
| D0601 |
|
294 |
294 |
$0.00 |