| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
7,190 |
7,190 |
$211K |
| D0120 |
Periodic oral evaluation - established patient |
8,489 |
8,489 |
$174K |
| D1110 |
Prophylaxis - adult |
2,978 |
2,978 |
$131K |
| D1208 |
Topical application of fluoride, excluding varnish |
8,691 |
8,691 |
$127K |
| D1351 |
Sealant - per tooth |
4,159 |
1,309 |
$97K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,129 |
732 |
$96K |
| D0330 |
Panoramic radiographic image |
1,853 |
1,853 |
$87K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
3,128 |
3,029 |
$78K |
| D0274 |
Bitewings - four radiographic images |
2,036 |
2,036 |
$60K |
| D0230 |
Intraoral - periapical each additional radiographic image |
7,849 |
2,764 |
$58K |
| D0220 |
Intraoral - periapical first radiographic image |
3,651 |
3,642 |
$54K |
| D0272 |
Bitewings - two radiographic images |
2,908 |
2,908 |
$51K |
| D7140 |
Extraction, erupted tooth or exposed root |
486 |
289 |
$30K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
214 |
149 |
$24K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
830 |
830 |
$24K |
| D1206 |
Topical application of fluoride varnish |
1,280 |
1,280 |
$19K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
113 |
77 |
$13K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
141 |
97 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
87 |
72 |
$5K |
| D2160 |
|
16 |
12 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
26 |
26 |
$745.10 |
| D3120 |
|
24 |
20 |
$701.50 |