| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
9,124 |
9,097 |
$255K |
| D1206 |
Topical application of fluoride varnish |
9,803 |
9,525 |
$241K |
| D0120 |
Periodic oral evaluation - established patient |
8,154 |
8,134 |
$194K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,092 |
652 |
$82K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,141 |
1,987 |
$64K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,008 |
654 |
$60K |
| D0272 |
Bitewings - two radiographic images |
4,156 |
4,130 |
$58K |
| D0145 |
Oral evaluation for a patient under three years of age |
945 |
943 |
$37K |
| D1351 |
Sealant - per tooth |
1,206 |
451 |
$31K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
264 |
93 |
$30K |
| D1110 |
Prophylaxis - adult |
289 |
288 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
1,428 |
1,384 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
386 |
386 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,413 |
728 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
66 |
36 |
$4K |
| D1999 |
|
170 |
165 |
$2K |
| D0274 |
Bitewings - four radiographic images |
25 |
25 |
$530.51 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$264.00 |