| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
10,134 |
10,094 |
$319K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,820 |
459 |
$209K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
4,323 |
4,307 |
$151K |
| D0120 |
Periodic oral evaluation - established patient |
6,519 |
6,488 |
$145K |
| D1206 |
Topical application of fluoride varnish |
7,806 |
7,785 |
$144K |
| D0230 |
Intraoral - periapical each additional radiographic image |
8,544 |
4,212 |
$114K |
| D0220 |
Intraoral - periapical first radiographic image |
7,887 |
7,826 |
$89K |
| D0272 |
Bitewings - two radiographic images |
3,710 |
3,693 |
$75K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,314 |
910 |
$71K |
| D0274 |
Bitewings - four radiographic images |
1,649 |
1,643 |
$48K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,529 |
2,509 |
$44K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
503 |
418 |
$35K |
| D0140 |
Limited oral evaluation - problem focused |
1,016 |
1,001 |
$29K |
| D9420 |
|
403 |
395 |
$29K |
| D7140 |
Extraction, erupted tooth or exposed root |
440 |
210 |
$29K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
855 |
830 |
$23K |
| D0240 |
|
1,779 |
1,760 |
$20K |
| D1351 |
Sealant - per tooth |
354 |
108 |
$8K |