| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
4,105 |
3,905 |
$135K |
| D1206 |
Topical application of fluoride varnish |
4,482 |
4,251 |
$117K |
| D1120 |
Prophylaxis - child |
4,185 |
3,972 |
$113K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
492 |
157 |
$92K |
| D1351 |
Sealant - per tooth |
3,073 |
725 |
$83K |
| D9999 |
Unspecified adjunctive procedure, by report |
1,308 |
1,239 |
$45K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
358 |
268 |
$30K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,098 |
1,010 |
$29K |
| D0272 |
Bitewings - two radiographic images |
2,856 |
2,708 |
$27K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
372 |
339 |
$18K |
| D1110 |
Prophylaxis - adult |
228 |
215 |
$10K |
| D0330 |
Panoramic radiographic image |
277 |
256 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
1,040 |
974 |
$9K |
| D7140 |
Extraction, erupted tooth or exposed root |
110 |
59 |
$6K |
| D0274 |
Bitewings - four radiographic images |
425 |
389 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
169 |
165 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
36 |
26 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
356 |
293 |
$777.36 |