| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,869 |
2,863 |
$128K |
| D0120 |
Periodic oral evaluation - established patient |
2,387 |
2,380 |
$68K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,725 |
2,718 |
$68K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
694 |
372 |
$49K |
| D9920 |
|
1,403 |
1,382 |
$35K |
| D1351 |
Sealant - per tooth |
1,174 |
218 |
$24K |
| D0272 |
Bitewings - two radiographic images |
1,786 |
1,783 |
$20K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
747 |
690 |
$18K |
| D0603 |
|
1,671 |
1,659 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
2,075 |
2,051 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
174 |
173 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,808 |
1,790 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
52 |
40 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
50 |
26 |
$2K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
17 |
14 |
$2K |
| D1206 |
Topical application of fluoride varnish |
15 |
15 |
$468.75 |
| D0330 |
Panoramic radiographic image |
14 |
13 |
$440.00 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$144.00 |