| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,199 |
3,161 |
$107K |
| D1206 |
Topical application of fluoride varnish |
3,618 |
3,566 |
$77K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
563 |
198 |
$66K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
837 |
410 |
$64K |
| D0120 |
Periodic oral evaluation - established patient |
2,320 |
2,295 |
$57K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
873 |
498 |
$56K |
| D7140 |
Extraction, erupted tooth or exposed root |
765 |
333 |
$51K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,523 |
1,499 |
$45K |
| D9248 |
|
396 |
380 |
$34K |
| D1351 |
Sealant - per tooth |
994 |
349 |
$32K |
| D0330 |
Panoramic radiographic image |
586 |
569 |
$27K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
800 |
763 |
$23K |
| D1110 |
Prophylaxis - adult |
528 |
516 |
$23K |
| D0272 |
Bitewings - two radiographic images |
1,085 |
1,072 |
$19K |
| D0220 |
Intraoral - periapical first radiographic image |
815 |
784 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
293 |
280 |
$7K |
| D2929 |
|
36 |
13 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
117 |
54 |
$1K |