| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
5,857 |
5,702 |
$195K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,255 |
550 |
$131K |
| D0120 |
Periodic oral evaluation - established patient |
4,662 |
4,559 |
$124K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,175 |
952 |
$120K |
| D1206 |
Topical application of fluoride varnish |
5,734 |
5,587 |
$115K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,682 |
1,626 |
$51K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
899 |
562 |
$44K |
| D1351 |
Sealant - per tooth |
1,266 |
437 |
$37K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
526 |
342 |
$35K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,315 |
1,206 |
$31K |
| D0272 |
Bitewings - two radiographic images |
2,175 |
2,120 |
$27K |
| D0220 |
Intraoral - periapical first radiographic image |
2,284 |
2,168 |
$17K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,262 |
857 |
$13K |
| D9420 |
|
226 |
217 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
488 |
464 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
285 |
270 |
$4K |
| D2330 |
|
71 |
41 |
$3K |
| D0330 |
Panoramic radiographic image |
69 |
64 |
$2K |
| D1110 |
Prophylaxis - adult |
94 |
92 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
33 |
32 |
$1K |
| D1354 |
|
20 |
12 |
$170.70 |
| D0240 |
|
15 |
14 |
$92.00 |