| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,909 |
3,867 |
$18K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,107 |
475 |
$13K |
| D1206 |
Topical application of fluoride varnish |
3,738 |
3,675 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
3,619 |
3,590 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
611 |
597 |
$6K |
| D0272 |
Bitewings - two radiographic images |
2,581 |
2,553 |
$5K |
| D1351 |
Sealant - per tooth |
612 |
156 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
790 |
774 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
590 |
489 |
$2K |
| D0274 |
Bitewings - four radiographic images |
540 |
534 |
$2K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
47 |
24 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
86 |
43 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
548 |
515 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
503 |
498 |
$1K |
| D0330 |
Panoramic radiographic image |
153 |
151 |
$1K |
| D1110 |
Prophylaxis - adult |
185 |
182 |
$1K |
| D0240 |
|
39 |
35 |
$110.82 |
| D0140 |
Limited oral evaluation - problem focused |
15 |
13 |
$103.32 |
| D0210 |
Intraoral - complete series of radiographic images |
34 |
33 |
$16.00 |
| D1999 |
|
35 |
25 |
$0.00 |