| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,940 |
1,918 |
$58K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
529 |
319 |
$31K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
620 |
604 |
$28K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,349 |
1,227 |
$25K |
| D1110 |
Prophylaxis - adult |
346 |
342 |
$18K |
| D1206 |
Topical application of fluoride varnish |
2,325 |
2,293 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
1,671 |
1,658 |
$12K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
658 |
600 |
$10K |
| D1330 |
|
2,270 |
2,242 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
112 |
75 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
322 |
315 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
1,562 |
1,538 |
$3K |
| D0272 |
Bitewings - two radiographic images |
660 |
654 |
$3K |
| D1351 |
Sealant - per tooth |
313 |
86 |
$2K |
| D0274 |
Bitewings - four radiographic images |
494 |
491 |
$2K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
20 |
12 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
41 |
24 |
$1K |
| D0601 |
|
106 |
106 |
$345.00 |
| D0603 |
|
83 |
83 |
$250.00 |
| D0602 |
|
15 |
15 |
$40.00 |