| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
6,491 |
6,371 |
$284K |
| D1206 |
Topical application of fluoride varnish |
7,459 |
7,320 |
$186K |
| D0120 |
Periodic oral evaluation - established patient |
6,196 |
6,079 |
$185K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,304 |
681 |
$167K |
| D1351 |
Sealant - per tooth |
4,660 |
948 |
$141K |
| D9248 |
|
523 |
484 |
$96K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
353 |
161 |
$59K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,043 |
1,020 |
$55K |
| D0272 |
Bitewings - two radiographic images |
2,663 |
2,614 |
$43K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
409 |
249 |
$39K |
| D1110 |
Prophylaxis - adult |
501 |
488 |
$31K |
| D7140 |
Extraction, erupted tooth or exposed root |
172 |
95 |
$18K |
| D0330 |
Panoramic radiographic image |
366 |
366 |
$17K |
| D0274 |
Bitewings - four radiographic images |
709 |
696 |
$17K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
687 |
655 |
$13K |
| D0140 |
Limited oral evaluation - problem focused |
235 |
232 |
$11K |
| D9310 |
|
58 |
57 |
$3K |
| D1330 |
|
491 |
478 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
81 |
78 |
$757.84 |
| D0240 |
|
26 |
25 |
$362.00 |