| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
11,591 |
11,591 |
$404K |
| D1206 |
Topical application of fluoride varnish |
15,615 |
15,615 |
$256K |
| D0120 |
Periodic oral evaluation - established patient |
10,616 |
10,616 |
$248K |
| D1110 |
Prophylaxis - adult |
4,187 |
4,187 |
$211K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,299 |
1,524 |
$196K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,735 |
3,735 |
$154K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,246 |
878 |
$128K |
| D0272 |
Bitewings - two radiographic images |
6,103 |
6,103 |
$116K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
896 |
538 |
$108K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
3,042 |
2,954 |
$97K |
| D0330 |
Panoramic radiographic image |
1,737 |
1,737 |
$86K |
| D0274 |
Bitewings - four radiographic images |
3,079 |
3,079 |
$86K |
| D7140 |
Extraction, erupted tooth or exposed root |
893 |
583 |
$82K |
| D1351 |
Sealant - per tooth |
2,657 |
817 |
$80K |
| D0220 |
Intraoral - periapical first radiographic image |
5,737 |
5,719 |
$76K |
| D0145 |
Oral evaluation for a patient under three years of age |
1,215 |
1,215 |
$47K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,987 |
3,127 |
$44K |
| D0140 |
Limited oral evaluation - problem focused |
650 |
649 |
$25K |
| D9248 |
|
58 |
57 |
$4K |
| D1354 |
|
121 |
30 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
20 |
20 |
$324.00 |