| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
7,236 |
6,687 |
$184K |
| D0120 |
Periodic oral evaluation - established patient |
6,768 |
6,307 |
$168K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,441 |
653 |
$132K |
| D1206 |
Topical application of fluoride varnish |
8,135 |
7,492 |
$123K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,626 |
2,253 |
$110K |
| D8670 |
Periodic orthodontic treatment visit |
1,130 |
1,059 |
$104K |
| D1351 |
Sealant - per tooth |
2,494 |
712 |
$64K |
| D0272 |
Bitewings - two radiographic images |
3,149 |
2,879 |
$52K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
649 |
389 |
$48K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,006 |
894 |
$40K |
| D1110 |
Prophylaxis - adult |
824 |
763 |
$29K |
| D0220 |
Intraoral - periapical first radiographic image |
1,914 |
1,744 |
$27K |
| D0330 |
Panoramic radiographic image |
473 |
435 |
$23K |
| D0240 |
|
1,296 |
648 |
$20K |
| D0140 |
Limited oral evaluation - problem focused |
469 |
433 |
$17K |
| D7140 |
Extraction, erupted tooth or exposed root |
276 |
165 |
$16K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,384 |
1,098 |
$16K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
50 |
15 |
$5K |
| D0274 |
Bitewings - four radiographic images |
71 |
64 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
50 |
26 |
$950.25 |