| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,094 |
3,088 |
$164K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
479 |
384 |
$116K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,964 |
3,958 |
$114K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
512 |
344 |
$99K |
| D1351 |
Sealant - per tooth |
2,506 |
632 |
$93K |
| D0330 |
Panoramic radiographic image |
637 |
636 |
$93K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,326 |
1,326 |
$89K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
501 |
333 |
$87K |
| D1110 |
Prophylaxis - adult |
1,035 |
1,035 |
$75K |
| D0120 |
Periodic oral evaluation - established patient |
2,803 |
2,797 |
$61K |
| D7140 |
Extraction, erupted tooth or exposed root |
415 |
291 |
$52K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
646 |
618 |
$30K |
| D0274 |
Bitewings - four radiographic images |
350 |
350 |
$23K |
| D0272 |
Bitewings - two radiographic images |
1,326 |
1,320 |
$23K |
| D0140 |
Limited oral evaluation - problem focused |
416 |
399 |
$21K |
| D1330 |
|
3,608 |
3,602 |
$15K |
| D0210 |
Intraoral - complete series of radiographic images |
165 |
165 |
$12K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
18 |
13 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
134 |
132 |
$1K |
| D9999 |
Unspecified adjunctive procedure, by report |
53 |
53 |
$925.00 |
| D1354 |
|
28 |
12 |
$245.29 |
| D9986 |
|
217 |
213 |
$0.00 |