| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
5,218 |
5,032 |
$168K |
| D1208 |
Topical application of fluoride, excluding varnish |
7,162 |
6,905 |
$147K |
| D1110 |
Prophylaxis - adult |
3,027 |
2,935 |
$126K |
| D0120 |
Periodic oral evaluation - established patient |
5,137 |
4,982 |
$123K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
4,323 |
4,158 |
$119K |
| D1352 |
|
4,145 |
800 |
$118K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,162 |
876 |
$81K |
| D0330 |
Panoramic radiographic image |
1,969 |
1,873 |
$71K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,332 |
2,110 |
$65K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,064 |
780 |
$62K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
415 |
242 |
$45K |
| D0272 |
Bitewings - two radiographic images |
2,589 |
2,499 |
$44K |
| D0274 |
Bitewings - four radiographic images |
1,705 |
1,649 |
$44K |
| D1354 |
|
4,433 |
793 |
$37K |
| D0220 |
Intraoral - periapical first radiographic image |
851 |
805 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
469 |
445 |
$10K |
| D1206 |
Topical application of fluoride varnish |
433 |
423 |
$9K |
| D2999 |
|
385 |
40 |
$9K |
| D1351 |
Sealant - per tooth |
242 |
89 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
92 |
52 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
88 |
55 |
$779.55 |