| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,447 |
2,331 |
$91K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
819 |
262 |
$62K |
| D1206 |
Topical application of fluoride varnish |
2,703 |
2,460 |
$45K |
| D0120 |
Periodic oral evaluation - established patient |
1,542 |
1,489 |
$40K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,884 |
1,155 |
$21K |
| D0220 |
Intraoral - periapical first radiographic image |
1,450 |
1,342 |
$18K |
| D0272 |
Bitewings - two radiographic images |
1,025 |
951 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
418 |
391 |
$15K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
376 |
345 |
$9K |
| D0145 |
Oral evaluation for a patient under three years of age |
307 |
292 |
$8K |
| D0603 |
|
1,644 |
1,545 |
$7K |
| D1351 |
Sealant - per tooth |
224 |
82 |
$6K |
| D1354 |
|
1,552 |
316 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
57 |
25 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
127 |
114 |
$4K |
| D0602 |
|
690 |
667 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
33 |
13 |
$3K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
27 |
12 |
$3K |
| D0330 |
Panoramic radiographic image |
71 |
68 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
25 |
14 |
$1K |
| D1330 |
|
2,357 |
2,233 |
$180.00 |