| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
8,776 |
8,605 |
$385K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,229 |
1,017 |
$283K |
| D1206 |
Topical application of fluoride varnish |
9,971 |
9,775 |
$245K |
| D1351 |
Sealant - per tooth |
6,439 |
1,520 |
$225K |
| D0120 |
Periodic oral evaluation - established patient |
6,942 |
6,813 |
$207K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,680 |
1,653 |
$88K |
| D0272 |
Bitewings - two radiographic images |
3,558 |
3,497 |
$55K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
523 |
270 |
$51K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
287 |
90 |
$45K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,846 |
1,754 |
$34K |
| D0330 |
Panoramic radiographic image |
764 |
742 |
$33K |
| D7140 |
Extraction, erupted tooth or exposed root |
212 |
119 |
$25K |
| D1330 |
|
1,896 |
1,856 |
$12K |
| D1110 |
Prophylaxis - adult |
98 |
98 |
$6K |
| D9248 |
|
29 |
28 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
113 |
104 |
$5K |
| D2940 |
|
83 |
29 |
$4K |
| D0240 |
|
399 |
393 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
362 |
350 |
$3K |
| D0274 |
Bitewings - four radiographic images |
104 |
104 |
$2K |
| D9310 |
|
37 |
37 |
$2K |
| D3120 |
|
50 |
26 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
13 |
13 |
$535.28 |
| D0230 |
Intraoral - periapical each additional radiographic image |
13 |
13 |
$96.00 |