| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
10,286 |
10,269 |
$358K |
| D0120 |
Periodic oral evaluation - established patient |
14,544 |
14,528 |
$353K |
| D1206 |
Topical application of fluoride varnish |
15,964 |
15,941 |
$312K |
| D1110 |
Prophylaxis - adult |
5,320 |
5,313 |
$249K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,429 |
932 |
$195K |
| D1351 |
Sealant - per tooth |
4,325 |
1,493 |
$154K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,160 |
852 |
$123K |
| D0272 |
Bitewings - two radiographic images |
4,724 |
4,715 |
$99K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
3,103 |
2,946 |
$97K |
| D0220 |
Intraoral - periapical first radiographic image |
5,574 |
5,526 |
$72K |
| D0274 |
Bitewings - four radiographic images |
2,344 |
2,342 |
$71K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,469 |
4,442 |
$66K |
| D0330 |
Panoramic radiographic image |
936 |
934 |
$50K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
962 |
960 |
$39K |
| D7140 |
Extraction, erupted tooth or exposed root |
351 |
243 |
$35K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
208 |
56 |
$29K |
| D1354 |
|
1,034 |
365 |
$24K |
| D0145 |
Oral evaluation for a patient under three years of age |
673 |
673 |
$21K |
| D0140 |
Limited oral evaluation - problem focused |
238 |
237 |
$8K |
| D1353 |
|
106 |
29 |
$4K |
| D0270 |
|
25 |
25 |
$314.00 |