| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
5,649 |
5,287 |
$183K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,179 |
382 |
$153K |
| D1206 |
Topical application of fluoride varnish |
5,819 |
5,444 |
$123K |
| D0120 |
Periodic oral evaluation - established patient |
4,424 |
4,165 |
$98K |
| D1351 |
Sealant - per tooth |
2,582 |
525 |
$63K |
| D1354 |
|
863 |
254 |
$59K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,756 |
1,626 |
$59K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
790 |
418 |
$45K |
| D7140 |
Extraction, erupted tooth or exposed root |
672 |
283 |
$43K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,588 |
1,334 |
$43K |
| D0272 |
Bitewings - two radiographic images |
1,815 |
1,676 |
$41K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
606 |
350 |
$28K |
| D0140 |
Limited oral evaluation - problem focused |
863 |
761 |
$27K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,196 |
962 |
$24K |
| D0220 |
Intraoral - periapical first radiographic image |
2,008 |
1,780 |
$19K |
| D1110 |
Prophylaxis - adult |
410 |
386 |
$17K |
| D0210 |
Intraoral - complete series of radiographic images |
404 |
328 |
$12K |
| D0240 |
|
832 |
368 |
$12K |
| D0330 |
Panoramic radiographic image |
216 |
204 |
$9K |
| D0274 |
Bitewings - four radiographic images |
55 |
51 |
$2K |