| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
7,897 |
7,897 |
$398K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,420 |
2,054 |
$355K |
| D1120 |
Prophylaxis - child |
10,061 |
10,061 |
$351K |
| D0120 |
Periodic oral evaluation - established patient |
13,240 |
13,240 |
$307K |
| D1206 |
Topical application of fluoride varnish |
16,817 |
16,817 |
$274K |
| D0274 |
Bitewings - four radiographic images |
8,477 |
8,477 |
$229K |
| D1351 |
Sealant - per tooth |
5,971 |
2,329 |
$179K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
4,460 |
4,119 |
$146K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,545 |
3,545 |
$143K |
| D0330 |
Panoramic radiographic image |
2,869 |
2,869 |
$136K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,543 |
1,088 |
$127K |
| D0272 |
Bitewings - two radiographic images |
5,777 |
5,777 |
$108K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
718 |
552 |
$92K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
459 |
296 |
$58K |
| D0220 |
Intraoral - periapical first radiographic image |
4,518 |
4,467 |
$58K |
| D0145 |
Oral evaluation for a patient under three years of age |
1,228 |
1,228 |
$49K |
| D7140 |
Extraction, erupted tooth or exposed root |
469 |
322 |
$41K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,434 |
3,167 |
$35K |
| D0240 |
|
1,667 |
861 |
$33K |
| D0140 |
Limited oral evaluation - problem focused |
499 |
494 |
$19K |
| D2335 |
|
54 |
26 |
$7K |
| D2394 |
|
37 |
32 |
$6K |
| D7111 |
|
68 |
55 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
214 |
214 |
$4K |
| D9920 |
|
48 |
47 |
$2K |
| D2330 |
|
16 |
12 |
$1K |