| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
6,563 |
6,548 |
$289K |
| D0120 |
Periodic oral evaluation - established patient |
6,324 |
6,313 |
$257K |
| D1206 |
Topical application of fluoride varnish |
6,633 |
6,616 |
$207K |
| D1351 |
Sealant - per tooth |
5,231 |
1,021 |
$202K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,379 |
1,003 |
$102K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,938 |
2,599 |
$72K |
| D7140 |
Extraction, erupted tooth or exposed root |
763 |
519 |
$69K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
882 |
650 |
$63K |
| D0272 |
Bitewings - two radiographic images |
3,043 |
3,038 |
$53K |
| D0220 |
Intraoral - periapical first radiographic image |
3,666 |
3,602 |
$43K |
| D0274 |
Bitewings - four radiographic images |
1,407 |
1,402 |
$30K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,064 |
3,037 |
$29K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
206 |
146 |
$25K |
| D0330 |
Panoramic radiographic image |
451 |
451 |
$24K |
| D0240 |
|
733 |
728 |
$20K |
| D0603 |
|
1,927 |
1,923 |
$18K |
| D0140 |
Limited oral evaluation - problem focused |
353 |
342 |
$15K |
| D1110 |
Prophylaxis - adult |
938 |
924 |
$8K |
| D0601 |
|
713 |
711 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
144 |
144 |
$5K |
| D0602 |
|
189 |
189 |
$2K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
21 |
15 |
$2K |
| D1354 |
|
59 |
24 |
$560.00 |