| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
12,022 |
11,779 |
$544K |
| D1206 |
Topical application of fluoride varnish |
13,889 |
13,624 |
$347K |
| D0120 |
Periodic oral evaluation - established patient |
11,286 |
11,067 |
$344K |
| D1351 |
Sealant - per tooth |
7,703 |
1,525 |
$275K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,110 |
744 |
$147K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
705 |
507 |
$73K |
| D0272 |
Bitewings - two radiographic images |
4,466 |
4,385 |
$71K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
458 |
284 |
$70K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,134 |
2,031 |
$40K |
| D0140 |
Limited oral evaluation - problem focused |
887 |
866 |
$40K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
728 |
718 |
$39K |
| D1330 |
|
5,291 |
5,222 |
$34K |
| D1110 |
Prophylaxis - adult |
502 |
498 |
$33K |
| D0330 |
Panoramic radiographic image |
696 |
682 |
$31K |
| D7140 |
Extraction, erupted tooth or exposed root |
225 |
154 |
$25K |
| D0274 |
Bitewings - four radiographic images |
786 |
786 |
$19K |
| D0145 |
Oral evaluation for a patient under three years of age |
301 |
300 |
$13K |
| D3120 |
|
225 |
184 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
493 |
490 |
$5K |
| D1354 |
|
497 |
168 |
$5K |
| D0240 |
|
217 |
211 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
74 |
74 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
12 |
12 |
$91.84 |