| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
4,037 |
3,974 |
$239K |
| D1206 |
Topical application of fluoride varnish |
5,373 |
5,295 |
$210K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
975 |
642 |
$191K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
973 |
614 |
$149K |
| D0120 |
Periodic oral evaluation - established patient |
3,195 |
3,154 |
$139K |
| D1351 |
Sealant - per tooth |
2,757 |
763 |
$125K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,241 |
1,212 |
$99K |
| D0330 |
Panoramic radiographic image |
1,065 |
1,057 |
$98K |
| D0272 |
Bitewings - two radiographic images |
2,422 |
2,391 |
$95K |
| D1110 |
Prophylaxis - adult |
1,113 |
1,100 |
$84K |
| D0274 |
Bitewings - four radiographic images |
1,400 |
1,375 |
$76K |
| D0140 |
Limited oral evaluation - problem focused |
955 |
949 |
$66K |
| D0145 |
Oral evaluation for a patient under three years of age |
462 |
462 |
$27K |
| D7140 |
Extraction, erupted tooth or exposed root |
96 |
63 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
513 |
508 |
$14K |
| D0210 |
Intraoral - complete series of radiographic images |
202 |
178 |
$12K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
96 |
76 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
33 |
24 |
$7K |
| D0240 |
|
156 |
152 |
$5K |
| D0270 |
|
25 |
24 |
$775.00 |