| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
5,333 |
5,119 |
$312K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,078 |
623 |
$169K |
| D0120 |
Periodic oral evaluation - established patient |
3,679 |
3,539 |
$148K |
| D1206 |
Topical application of fluoride varnish |
5,429 |
5,201 |
$128K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
499 |
217 |
$106K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,375 |
1,312 |
$86K |
| D1351 |
Sealant - per tooth |
1,897 |
471 |
$85K |
| D0272 |
Bitewings - two radiographic images |
1,932 |
1,840 |
$50K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,269 |
1,134 |
$50K |
| D7140 |
Extraction, erupted tooth or exposed root |
330 |
175 |
$38K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
289 |
203 |
$37K |
| D0140 |
Limited oral evaluation - problem focused |
327 |
312 |
$20K |
| D1354 |
|
514 |
150 |
$11K |
| D0603 |
|
1,108 |
1,068 |
$8K |
| D0240 |
|
1,103 |
673 |
$8K |
| D1110 |
Prophylaxis - adult |
109 |
107 |
$7K |
| D0330 |
Panoramic radiographic image |
108 |
105 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
52 |
51 |
$3K |
| D0274 |
Bitewings - four radiographic images |
57 |
57 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
255 |
247 |
$2K |
| D0601 |
|
209 |
201 |
$2K |
| D1352 |
|
20 |
12 |
$900.00 |
| D0602 |
|
130 |
127 |
$870.00 |
| D1330 |
|
30 |
30 |
$0.00 |