| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
4,965 |
4,850 |
$264K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,951 |
705 |
$223K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,555 |
3,462 |
$100K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,103 |
686 |
$74K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,087 |
543 |
$73K |
| D1206 |
Topical application of fluoride varnish |
3,827 |
3,731 |
$64K |
| D0272 |
Bitewings - two radiographic images |
3,240 |
3,133 |
$61K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,016 |
659 |
$55K |
| D0120 |
Periodic oral evaluation - established patient |
2,174 |
2,125 |
$55K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,537 |
1,397 |
$50K |
| D0330 |
Panoramic radiographic image |
790 |
770 |
$42K |
| D0220 |
Intraoral - periapical first radiographic image |
2,889 |
2,784 |
$32K |
| D0140 |
Limited oral evaluation - problem focused |
749 |
712 |
$29K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,417 |
1,884 |
$28K |
| D1351 |
Sealant - per tooth |
1,135 |
370 |
$24K |
| D1110 |
Prophylaxis - adult |
455 |
435 |
$23K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,346 |
1,320 |
$19K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
103 |
56 |
$5K |
| D0274 |
Bitewings - four radiographic images |
139 |
138 |
$4K |
| D9110 |
|
100 |
99 |
$2K |
| D2330 |
|
30 |
13 |
$1K |
| D1330 |
|
18 |
18 |
$263.34 |
| D9986 |
|
22 |
18 |
$0.00 |