| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
8,197 |
8,137 |
$270K |
| D0120 |
Periodic oral evaluation - established patient |
8,185 |
8,121 |
$208K |
| D1208 |
Topical application of fluoride, excluding varnish |
9,504 |
9,439 |
$177K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,464 |
1,021 |
$114K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,480 |
2,271 |
$88K |
| D0272 |
Bitewings - two radiographic images |
4,159 |
4,104 |
$81K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
533 |
206 |
$66K |
| D1351 |
Sealant - per tooth |
2,173 |
642 |
$58K |
| D1110 |
Prophylaxis - adult |
1,340 |
1,329 |
$57K |
| D7140 |
Extraction, erupted tooth or exposed root |
727 |
511 |
$54K |
| D0145 |
Oral evaluation for a patient under three years of age |
1,152 |
1,151 |
$49K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
354 |
277 |
$22K |
| D0220 |
Intraoral - periapical first radiographic image |
1,619 |
1,571 |
$22K |
| D0140 |
Limited oral evaluation - problem focused |
883 |
844 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
162 |
161 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
97 |
49 |
$495.22 |