| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
12,106 |
11,080 |
$308K |
| D0120 |
Periodic oral evaluation - established patient |
11,965 |
10,936 |
$290K |
| D1206 |
Topical application of fluoride varnish |
12,538 |
11,466 |
$188K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,544 |
919 |
$149K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,027 |
1,099 |
$149K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,818 |
1,549 |
$74K |
| D0272 |
Bitewings - two radiographic images |
4,116 |
3,754 |
$70K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,061 |
987 |
$45K |
| D1110 |
Prophylaxis - adult |
730 |
662 |
$26K |
| D0140 |
Limited oral evaluation - problem focused |
622 |
577 |
$22K |
| D0240 |
|
1,029 |
549 |
$16K |
| D0330 |
Panoramic radiographic image |
172 |
148 |
$9K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
52 |
12 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
514 |
477 |
$7K |
| D0274 |
Bitewings - four radiographic images |
31 |
27 |
$872.30 |
| D0230 |
Intraoral - periapical each additional radiographic image |
38 |
28 |
$462.96 |