| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
11,926 |
11,926 |
$595K |
| D0120 |
Periodic oral evaluation - established patient |
11,165 |
11,165 |
$395K |
| D1206 |
Topical application of fluoride varnish |
11,056 |
11,055 |
$361K |
| D1351 |
Sealant - per tooth |
2,351 |
672 |
$104K |
| D1110 |
Prophylaxis - adult |
1,578 |
1,578 |
$100K |
| D0272 |
Bitewings - two radiographic images |
4,767 |
4,767 |
$89K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,192 |
2,192 |
$83K |
| D0330 |
Panoramic radiographic image |
1,494 |
1,494 |
$65K |
| D0220 |
Intraoral - periapical first radiographic image |
3,773 |
3,767 |
$56K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,100 |
2,100 |
$41K |
| D7140 |
Extraction, erupted tooth or exposed root |
591 |
374 |
$40K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
499 |
326 |
$39K |
| D0274 |
Bitewings - four radiographic images |
1,183 |
1,183 |
$37K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,245 |
2,245 |
$33K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
263 |
174 |
$21K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
445 |
433 |
$8K |
| D0240 |
|
236 |
170 |
$7K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
53 |
39 |
$6K |
| D1354 |
|
150 |
46 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
14 |
14 |
$147.00 |