| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
6,757 |
6,720 |
$168K |
| D1120 |
Prophylaxis - child |
4,743 |
4,716 |
$168K |
| D1206 |
Topical application of fluoride varnish |
6,833 |
6,794 |
$141K |
| D1110 |
Prophylaxis - adult |
2,129 |
2,117 |
$94K |
| D0272 |
Bitewings - two radiographic images |
2,207 |
2,191 |
$49K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
329 |
104 |
$32K |
| D0274 |
Bitewings - four radiographic images |
910 |
900 |
$24K |
| D0330 |
Panoramic radiographic image |
576 |
574 |
$23K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
193 |
116 |
$16K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
933 |
895 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
108 |
90 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
130 |
79 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
544 |
535 |
$7K |
| D1351 |
Sealant - per tooth |
158 |
42 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
76 |
75 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
19 |
12 |
$149.88 |