| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
6,150 |
6,141 |
$242K |
| D1206 |
Topical application of fluoride varnish |
8,637 |
8,601 |
$193K |
| D0120 |
Periodic oral evaluation - established patient |
7,082 |
7,072 |
$185K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,339 |
782 |
$175K |
| D1351 |
Sealant - per tooth |
2,707 |
878 |
$104K |
| D1110 |
Prophylaxis - adult |
1,756 |
1,753 |
$94K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,947 |
1,945 |
$84K |
| D7140 |
Extraction, erupted tooth or exposed root |
734 |
493 |
$76K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
564 |
422 |
$58K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,785 |
1,698 |
$57K |
| D0210 |
Intraoral - complete series of radiographic images |
702 |
701 |
$56K |
| D0272 |
Bitewings - two radiographic images |
2,439 |
2,435 |
$53K |
| D0220 |
Intraoral - periapical first radiographic image |
2,289 |
2,269 |
$30K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,196 |
1,193 |
$24K |
| D0274 |
Bitewings - four radiographic images |
508 |
507 |
$16K |
| D0140 |
Limited oral evaluation - problem focused |
413 |
409 |
$15K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
55 |
24 |
$7K |
| D2991 |
|
33 |
12 |
$2K |
| D0330 |
Panoramic radiographic image |
14 |
14 |
$766.60 |