| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
10,313 |
10,184 |
$469K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,623 |
1,263 |
$281K |
| D1206 |
Topical application of fluoride varnish |
10,926 |
10,782 |
$256K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,289 |
544 |
$235K |
| D0120 |
Periodic oral evaluation - established patient |
8,312 |
8,228 |
$215K |
| D1351 |
Sealant - per tooth |
3,651 |
1,380 |
$131K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
1,117 |
565 |
$90K |
| D0272 |
Bitewings - two radiographic images |
3,307 |
3,262 |
$89K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,071 |
728 |
$85K |
| D1110 |
Prophylaxis - adult |
1,162 |
1,142 |
$70K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
3,400 |
3,027 |
$69K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,067 |
1,053 |
$59K |
| D0274 |
Bitewings - four radiographic images |
1,299 |
1,281 |
$49K |
| D0330 |
Panoramic radiographic image |
630 |
620 |
$49K |
| D7140 |
Extraction, erupted tooth or exposed root |
256 |
183 |
$25K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
162 |
127 |
$19K |
| D0220 |
Intraoral - periapical first radiographic image |
960 |
931 |
$17K |
| D9920 |
|
149 |
140 |
$12K |
| D0140 |
Limited oral evaluation - problem focused |
143 |
140 |
$6K |
| D0145 |
Oral evaluation for a patient under three years of age |
85 |
85 |
$2K |
| D3120 |
|
38 |
29 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
56 |
28 |
$520.00 |