| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,564 |
3,552 |
$175K |
| D0120 |
Periodic oral evaluation - established patient |
3,236 |
3,226 |
$103K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,452 |
753 |
$98K |
| D1206 |
Topical application of fluoride varnish |
3,172 |
3,162 |
$95K |
| D1351 |
Sealant - per tooth |
3,365 |
743 |
$81K |
| D0272 |
Bitewings - two radiographic images |
2,046 |
2,039 |
$26K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
139 |
93 |
$19K |
| D0220 |
Intraoral - periapical first radiographic image |
2,451 |
2,444 |
$17K |
| D0603 |
|
3,358 |
3,344 |
$15K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
580 |
564 |
$15K |
| D0274 |
Bitewings - four radiographic images |
690 |
686 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,965 |
1,959 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
284 |
284 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
140 |
83 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
531 |
531 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
131 |
130 |
$4K |
| D0330 |
Panoramic radiographic image |
77 |
77 |
$4K |
| D1110 |
Prophylaxis - adult |
14 |
14 |
$784.00 |
| D9920 |
|
14 |
14 |
$468.00 |
| D0602 |
|
49 |
49 |
$300.00 |
| D1330 |
|
814 |
814 |
$0.00 |
| D1999 |
|
121 |
116 |
$0.00 |