| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
18,449 |
18,187 |
$794K |
| D1206 |
Topical application of fluoride varnish |
24,502 |
24,173 |
$599K |
| D0120 |
Periodic oral evaluation - established patient |
19,315 |
19,050 |
$562K |
| D1351 |
Sealant - per tooth |
13,598 |
3,298 |
$462K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
4,055 |
2,207 |
$376K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,818 |
1,235 |
$336K |
| D9248 |
|
1,228 |
1,103 |
$227K |
| D1110 |
Prophylaxis - adult |
3,300 |
3,268 |
$190K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,545 |
840 |
$155K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,811 |
1,787 |
$91K |
| D0272 |
Bitewings - two radiographic images |
5,746 |
5,658 |
$86K |
| D0330 |
Panoramic radiographic image |
1,113 |
1,097 |
$46K |
| D0274 |
Bitewings - four radiographic images |
1,917 |
1,895 |
$42K |
| D1330 |
|
6,497 |
6,417 |
$39K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
182 |
65 |
$28K |
| D0140 |
Limited oral evaluation - problem focused |
510 |
492 |
$22K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,166 |
1,118 |
$22K |
| D0145 |
Oral evaluation for a patient under three years of age |
237 |
235 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
50 |
49 |
$441.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
12 |
12 |
$234.00 |