| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,277 |
1,126 |
$48K |
| D1206 |
Topical application of fluoride varnish |
1,247 |
1,118 |
$37K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
763 |
158 |
$33K |
| D1351 |
Sealant - per tooth |
1,766 |
347 |
$29K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
795 |
301 |
$26K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
561 |
513 |
$16K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
462 |
228 |
$13K |
| D0274 |
Bitewings - four radiographic images |
633 |
550 |
$11K |
| D7140 |
Extraction, erupted tooth or exposed root |
391 |
141 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
627 |
536 |
$10K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
507 |
393 |
$8K |
| D0330 |
Panoramic radiographic image |
223 |
192 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,399 |
648 |
$7K |
| D0272 |
Bitewings - two radiographic images |
395 |
328 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
680 |
543 |
$5K |
| D0603 |
|
1,247 |
1,078 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
176 |
152 |
$4K |
| D9420 |
|
255 |
134 |
$4K |
| D0350 |
|
362 |
273 |
$4K |
| D2933 |
|
37 |
14 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
20 |
12 |
$889.70 |
| D0240 |
|
97 |
58 |
$749.42 |
| D0170 |
|
26 |
25 |
$442.56 |
| D7111 |
|
30 |
12 |
$124.00 |
| D0602 |
|
15 |
14 |
$45.00 |
| D1330 |
|
514 |
448 |
$0.00 |