| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
7,795 |
7,765 |
$392K |
| D0120 |
Periodic oral evaluation - established patient |
3,957 |
3,950 |
$288K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,786 |
2,764 |
$186K |
| D1310 |
|
2,629 |
2,613 |
$109K |
| D1206 |
Topical application of fluoride varnish |
5,287 |
5,279 |
$102K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
973 |
545 |
$64K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,456 |
1,348 |
$58K |
| D0230 |
Intraoral - periapical each additional radiographic image |
14,372 |
4,700 |
$57K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,002 |
1,989 |
$42K |
| D0145 |
Oral evaluation for a patient under three years of age |
508 |
508 |
$36K |
| D0603 |
|
2,347 |
2,334 |
$31K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
270 |
82 |
$30K |
| D0220 |
Intraoral - periapical first radiographic image |
2,373 |
2,350 |
$28K |
| D1351 |
Sealant - per tooth |
699 |
207 |
$26K |
| D0350 |
|
2,388 |
1,081 |
$22K |
| D0272 |
Bitewings - two radiographic images |
1,661 |
1,650 |
$19K |
| D7140 |
Extraction, erupted tooth or exposed root |
306 |
133 |
$17K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
285 |
165 |
$15K |
| D9430 |
|
231 |
227 |
$7K |
| D0274 |
Bitewings - four radiographic images |
260 |
256 |
$5K |
| D0240 |
|
91 |
88 |
$900.00 |
| D0602 |
|
41 |
41 |
$611.25 |
| D0601 |
|
41 |
40 |
$600.00 |
| D0330 |
Panoramic radiographic image |
18 |
18 |
$540.00 |