| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
7,920 |
6,771 |
$270K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,763 |
670 |
$241K |
| D1206 |
Topical application of fluoride varnish |
7,304 |
6,215 |
$166K |
| D0120 |
Periodic oral evaluation - established patient |
5,581 |
4,804 |
$147K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,404 |
844 |
$139K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,628 |
934 |
$134K |
| D0272 |
Bitewings - two radiographic images |
3,881 |
3,258 |
$98K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,240 |
1,938 |
$90K |
| D1351 |
Sealant - per tooth |
3,182 |
997 |
$87K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,842 |
2,261 |
$80K |
| D7140 |
Extraction, erupted tooth or exposed root |
894 |
434 |
$67K |
| D0330 |
Panoramic radiographic image |
1,016 |
877 |
$66K |
| D0145 |
Oral evaluation for a patient under three years of age |
434 |
361 |
$15K |
| D0274 |
Bitewings - four radiographic images |
449 |
323 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
517 |
441 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
104 |
98 |
$5K |
| D1110 |
Prophylaxis - adult |
21 |
12 |
$743.32 |
| D0270 |
|
26 |
26 |
$429.29 |