| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
4,880 |
4,340 |
$209K |
| D1206 |
Topical application of fluoride varnish |
5,229 |
4,705 |
$188K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,149 |
322 |
$156K |
| D0120 |
Periodic oral evaluation - established patient |
4,878 |
4,354 |
$114K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,338 |
609 |
$113K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
993 |
710 |
$104K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,087 |
719 |
$82K |
| D1351 |
Sealant - per tooth |
2,486 |
816 |
$81K |
| D1110 |
Prophylaxis - adult |
952 |
859 |
$57K |
| D9420 |
|
250 |
240 |
$55K |
| D0272 |
Bitewings - two radiographic images |
1,682 |
1,478 |
$40K |
| D0274 |
Bitewings - four radiographic images |
1,051 |
905 |
$35K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
749 |
639 |
$24K |
| D0330 |
Panoramic radiographic image |
336 |
312 |
$21K |
| D0140 |
Limited oral evaluation - problem focused |
485 |
427 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
497 |
422 |
$17K |
| D1208 |
Topical application of fluoride, excluding varnish |
573 |
457 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
740 |
618 |
$11K |
| D2335 |
|
67 |
38 |
$10K |
| D0240 |
|
309 |
266 |
$9K |
| D0210 |
Intraoral - complete series of radiographic images |
52 |
52 |
$4K |
| D2330 |
|
55 |
37 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
130 |
101 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
38 |
28 |
$1K |
| D9920 |
|
17 |
17 |
$1K |