| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
9,215 |
9,209 |
$383K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,748 |
1,987 |
$245K |
| D0120 |
Periodic oral evaluation - established patient |
8,239 |
8,232 |
$228K |
| D1351 |
Sealant - per tooth |
2,204 |
1,028 |
$121K |
| D1208 |
Topical application of fluoride, excluding varnish |
8,403 |
8,394 |
$115K |
| D1110 |
Prophylaxis - adult |
2,025 |
2,022 |
$109K |
| D1206 |
Topical application of fluoride varnish |
2,251 |
2,250 |
$65K |
| D0330 |
Panoramic radiographic image |
1,269 |
1,269 |
$49K |
| D7140 |
Extraction, erupted tooth or exposed root |
691 |
487 |
$48K |
| D0272 |
Bitewings - two radiographic images |
2,448 |
2,447 |
$41K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,209 |
1,209 |
$35K |
| D0274 |
Bitewings - four radiographic images |
1,084 |
1,083 |
$31K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,760 |
1,632 |
$19K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
43 |
27 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
152 |
122 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
273 |
270 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
101 |
101 |
$1K |
| D0145 |
Oral evaluation for a patient under three years of age |
29 |
29 |
$850.50 |
| D9110 |
|
14 |
14 |
$275.66 |