| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
5,365 |
5,299 |
$133K |
| D1206 |
Topical application of fluoride varnish |
7,573 |
7,473 |
$114K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,459 |
969 |
$96K |
| D1351 |
Sealant - per tooth |
3,438 |
982 |
$87K |
| D0120 |
Periodic oral evaluation - established patient |
6,109 |
6,035 |
$83K |
| D9630 |
|
5,560 |
5,475 |
$78K |
| D1110 |
Prophylaxis - adult |
2,327 |
2,289 |
$75K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,316 |
2,108 |
$58K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,553 |
1,523 |
$46K |
| D0330 |
Panoramic radiographic image |
906 |
895 |
$45K |
| D0240 |
|
5,470 |
2,732 |
$44K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
719 |
495 |
$41K |
| D7140 |
Extraction, erupted tooth or exposed root |
461 |
288 |
$25K |
| D9994 |
|
4,861 |
4,808 |
$22K |
| D0272 |
Bitewings - two radiographic images |
1,495 |
1,470 |
$21K |
| D0274 |
Bitewings - four radiographic images |
1,140 |
1,123 |
$20K |
| D0210 |
Intraoral - complete series of radiographic images |
2,070 |
778 |
$14K |
| D0140 |
Limited oral evaluation - problem focused |
647 |
630 |
$12K |
| D3120 |
|
492 |
388 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
686 |
677 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
448 |
215 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
20 |
17 |
$2K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
16 |
13 |
$2K |