| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
12,275 |
11,525 |
$518K |
| D1206 |
Topical application of fluoride varnish |
12,258 |
11,501 |
$424K |
| D0120 |
Periodic oral evaluation - established patient |
10,593 |
9,943 |
$219K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,533 |
1,113 |
$164K |
| D1351 |
Sealant - per tooth |
4,361 |
1,222 |
$144K |
| D0272 |
Bitewings - two radiographic images |
4,986 |
4,720 |
$120K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,455 |
1,053 |
$112K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,123 |
749 |
$95K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,019 |
1,814 |
$60K |
| D1110 |
Prophylaxis - adult |
880 |
836 |
$54K |
| D0330 |
Panoramic radiographic image |
804 |
768 |
$48K |
| D0274 |
Bitewings - four radiographic images |
1,157 |
1,075 |
$39K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
846 |
775 |
$30K |
| D0240 |
|
548 |
496 |
$24K |
| D0220 |
Intraoral - periapical first radiographic image |
1,488 |
1,375 |
$22K |
| D0140 |
Limited oral evaluation - problem focused |
619 |
604 |
$20K |
| D1310 |
|
265 |
163 |
$9K |
| D1330 |
|
265 |
163 |
$8K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
25 |
13 |
$3K |
| D0270 |
|
89 |
65 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
81 |
72 |
$1K |
| D0350 |
|
16 |
16 |
$640.00 |