| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
13,722 |
13,553 |
$578K |
| D1206 |
Topical application of fluoride varnish |
13,445 |
13,247 |
$356K |
| D0120 |
Periodic oral evaluation - established patient |
10,794 |
10,645 |
$345K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,584 |
1,546 |
$253K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,564 |
1,520 |
$211K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,396 |
2,367 |
$145K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,508 |
2,366 |
$138K |
| D0272 |
Bitewings - two radiographic images |
4,373 |
4,325 |
$127K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,060 |
545 |
$112K |
| D1351 |
Sealant - per tooth |
2,356 |
792 |
$84K |
| D0330 |
Panoramic radiographic image |
583 |
575 |
$44K |
| D1354 |
|
3,224 |
894 |
$33K |
| D0220 |
Intraoral - periapical first radiographic image |
1,795 |
1,773 |
$32K |
| D0230 |
Intraoral - periapical each additional radiographic image |
735 |
494 |
$11K |
| D0274 |
Bitewings - four radiographic images |
210 |
210 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
210 |
201 |
$9K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
48 |
13 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
29 |
29 |
$824.18 |