| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
8,318 |
7,497 |
$244K |
| D1206 |
Topical application of fluoride varnish |
9,744 |
8,775 |
$185K |
| D0120 |
Periodic oral evaluation - established patient |
8,060 |
7,348 |
$158K |
| D1351 |
Sealant - per tooth |
4,244 |
813 |
$108K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
755 |
243 |
$102K |
| D0272 |
Bitewings - two radiographic images |
3,909 |
3,472 |
$80K |
| D1110 |
Prophylaxis - adult |
1,527 |
1,410 |
$63K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,024 |
533 |
$62K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,807 |
1,559 |
$48K |
| D7140 |
Extraction, erupted tooth or exposed root |
534 |
252 |
$32K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,077 |
919 |
$31K |
| D0140 |
Limited oral evaluation - problem focused |
631 |
547 |
$18K |
| D0240 |
|
977 |
393 |
$14K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
297 |
172 |
$13K |
| D0330 |
Panoramic radiographic image |
242 |
224 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
502 |
405 |
$5K |
| D0274 |
Bitewings - four radiographic images |
141 |
127 |
$4K |
| D0145 |
Oral evaluation for a patient under three years of age |
90 |
83 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
110 |
24 |
$548.00 |