| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,954 |
3,939 |
$88K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
492 |
254 |
$57K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
966 |
494 |
$56K |
| D1206 |
Topical application of fluoride varnish |
3,574 |
3,564 |
$49K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,231 |
1,230 |
$30K |
| D0120 |
Periodic oral evaluation - established patient |
2,433 |
2,425 |
$29K |
| D7140 |
Extraction, erupted tooth or exposed root |
494 |
250 |
$25K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,054 |
1,000 |
$25K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,928 |
1,643 |
$23K |
| D0272 |
Bitewings - two radiographic images |
1,220 |
1,220 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
1,909 |
1,888 |
$14K |
| D1351 |
Sealant - per tooth |
718 |
231 |
$14K |
| D9920 |
|
147 |
139 |
$7K |
| D0145 |
Oral evaluation for a patient under three years of age |
323 |
323 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
308 |
301 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
290 |
283 |
$5K |
| D3120 |
|
266 |
166 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
57 |
37 |
$2K |
| D1110 |
Prophylaxis - adult |
80 |
80 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
16 |
13 |
$2K |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$0.00 |