| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
11,142 |
10,987 |
$493K |
| D1206 |
Topical application of fluoride varnish |
14,598 |
14,391 |
$364K |
| D0120 |
Periodic oral evaluation - established patient |
10,038 |
9,894 |
$301K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,907 |
1,098 |
$239K |
| D1351 |
Sealant - per tooth |
6,257 |
1,352 |
$220K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,315 |
2,282 |
$122K |
| D0272 |
Bitewings - two radiographic images |
5,404 |
5,325 |
$84K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
3,103 |
2,779 |
$58K |
| D1110 |
Prophylaxis - adult |
682 |
678 |
$44K |
| D0330 |
Panoramic radiographic image |
942 |
933 |
$41K |
| D7140 |
Extraction, erupted tooth or exposed root |
327 |
170 |
$36K |
| D0274 |
Bitewings - four radiographic images |
1,475 |
1,458 |
$34K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
310 |
196 |
$31K |
| D1330 |
|
4,941 |
4,842 |
$31K |
| D8670 |
Periodic orthodontic treatment visit |
183 |
173 |
$14K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
80 |
37 |
$13K |
| D0140 |
Limited oral evaluation - problem focused |
83 |
79 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
92 |
92 |
$2K |
| D0240 |
|
28 |
28 |
$405.00 |
| D0220 |
Intraoral - periapical first radiographic image |
38 |
38 |
$342.00 |