| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
8,383 |
8,378 |
$323K |
| D1206 |
Topical application of fluoride varnish |
9,161 |
9,156 |
$200K |
| D0120 |
Periodic oral evaluation - established patient |
6,796 |
6,791 |
$178K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,226 |
420 |
$152K |
| D1351 |
Sealant - per tooth |
2,782 |
797 |
$100K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,805 |
2,801 |
$97K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,921 |
1,920 |
$79K |
| D1110 |
Prophylaxis - adult |
1,082 |
1,082 |
$58K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,731 |
1,686 |
$56K |
| D0220 |
Intraoral - periapical first radiographic image |
3,756 |
3,723 |
$48K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
435 |
266 |
$44K |
| D7140 |
Extraction, erupted tooth or exposed root |
374 |
222 |
$37K |
| D0140 |
Limited oral evaluation - problem focused |
848 |
846 |
$31K |
| D0330 |
Panoramic radiographic image |
563 |
563 |
$30K |
| D0272 |
Bitewings - two radiographic images |
820 |
820 |
$18K |
| D0240 |
|
500 |
498 |
$15K |
| D0145 |
Oral evaluation for a patient under three years of age |
449 |
449 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
98 |
62 |
$13K |
| D0274 |
Bitewings - four radiographic images |
148 |
148 |
$5K |