| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,346 |
3,320 |
$157K |
| D1351 |
Sealant - per tooth |
3,135 |
642 |
$116K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
860 |
433 |
$115K |
| D1206 |
Topical application of fluoride varnish |
4,198 |
4,164 |
$106K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
531 |
199 |
$92K |
| D7140 |
Extraction, erupted tooth or exposed root |
629 |
274 |
$81K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,408 |
1,392 |
$77K |
| D0120 |
Periodic oral evaluation - established patient |
2,331 |
2,318 |
$73K |
| D0140 |
Limited oral evaluation - problem focused |
1,131 |
1,087 |
$52K |
| D3120 |
|
813 |
265 |
$28K |
| D0272 |
Bitewings - two radiographic images |
1,364 |
1,348 |
$22K |
| D1110 |
Prophylaxis - adult |
231 |
230 |
$15K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
765 |
669 |
$15K |
| D1330 |
|
2,003 |
1,993 |
$14K |
| D0274 |
Bitewings - four radiographic images |
230 |
229 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
410 |
406 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
41 |
26 |
$4K |
| D2940 |
|
52 |
13 |
$3K |
| D0330 |
Panoramic radiographic image |
32 |
29 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
100 |
100 |
$1K |
| D9420 |
|
51 |
51 |
$765.00 |
| D9310 |
|
13 |
13 |
$624.00 |
| D0240 |
|
30 |
30 |
$297.00 |