| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
5,581 |
5,127 |
$197K |
| D1120 |
Prophylaxis - child |
4,386 |
3,837 |
$188K |
| D0120 |
Periodic oral evaluation - established patient |
4,318 |
3,795 |
$102K |
| D1110 |
Prophylaxis - adult |
1,439 |
1,351 |
$81K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
537 |
109 |
$72K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
816 |
511 |
$59K |
| D7140 |
Extraction, erupted tooth or exposed root |
632 |
225 |
$50K |
| D0274 |
Bitewings - four radiographic images |
1,456 |
1,357 |
$45K |
| D1351 |
Sealant - per tooth |
1,293 |
383 |
$41K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,249 |
1,152 |
$38K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
342 |
215 |
$34K |
| D0272 |
Bitewings - two radiographic images |
1,447 |
1,206 |
$33K |
| D0330 |
Panoramic radiographic image |
397 |
394 |
$23K |
| D9420 |
|
78 |
50 |
$17K |
| D0220 |
Intraoral - periapical first radiographic image |
1,010 |
899 |
$14K |
| D0140 |
Limited oral evaluation - problem focused |
412 |
359 |
$13K |
| T1015 |
Clinic visit/encounter, all-inclusive |
111 |
110 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
342 |
128 |
$10K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
198 |
125 |
$6K |
| D1354 |
|
114 |
33 |
$3K |
| D0240 |
|
69 |
31 |
$2K |