| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
15,743 |
14,913 |
$417K |
| D0120 |
Periodic oral evaluation - established patient |
14,934 |
14,220 |
$383K |
| D1206 |
Topical application of fluoride varnish |
17,405 |
16,492 |
$274K |
| D0272 |
Bitewings - two radiographic images |
6,308 |
5,986 |
$115K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
830 |
280 |
$112K |
| D1351 |
Sealant - per tooth |
3,458 |
674 |
$97K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,824 |
1,677 |
$77K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,467 |
1,250 |
$61K |
| D0240 |
|
3,934 |
2,048 |
$61K |
| D0140 |
Limited oral evaluation - problem focused |
1,299 |
1,191 |
$47K |
| D1110 |
Prophylaxis - adult |
1,094 |
1,039 |
$41K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
356 |
227 |
$36K |
| D0330 |
Panoramic radiographic image |
428 |
403 |
$24K |
| D0220 |
Intraoral - periapical first radiographic image |
1,551 |
1,478 |
$23K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
72 |
50 |
$6K |
| D0274 |
Bitewings - four radiographic images |
148 |
145 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
80 |
25 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
69 |
29 |
$816.48 |