| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
7,708 |
7,706 |
$279K |
| D0120 |
Periodic oral evaluation - established patient |
6,927 |
6,926 |
$160K |
| D1206 |
Topical application of fluoride varnish |
4,607 |
4,602 |
$103K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,309 |
870 |
$95K |
| D0272 |
Bitewings - two radiographic images |
4,096 |
4,095 |
$54K |
| D0220 |
Intraoral - periapical first radiographic image |
5,461 |
5,449 |
$53K |
| D1351 |
Sealant - per tooth |
1,199 |
470 |
$49K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,437 |
3,437 |
$42K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,289 |
1,289 |
$32K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,579 |
4,575 |
$30K |
| D1110 |
Prophylaxis - adult |
509 |
509 |
$23K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
276 |
218 |
$13K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
467 |
451 |
$8K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
58 |
53 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
121 |
99 |
$6K |
| D0274 |
Bitewings - four radiographic images |
93 |
93 |
$2K |
| D0330 |
Panoramic radiographic image |
54 |
54 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
54 |
54 |
$629.68 |
| D0240 |
|
29 |
27 |
$388.02 |