| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
4,406 |
4,387 |
$189K |
| D0120 |
Periodic oral evaluation - established patient |
2,686 |
2,671 |
$175K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,453 |
1,448 |
$94K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,909 |
3,890 |
$66K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
466 |
217 |
$56K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,078 |
991 |
$43K |
| D0272 |
Bitewings - two radiographic images |
3,281 |
3,266 |
$38K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
570 |
319 |
$38K |
| D0230 |
Intraoral - periapical each additional radiographic image |
7,906 |
4,027 |
$31K |
| D1351 |
Sealant - per tooth |
677 |
201 |
$26K |
| D0145 |
Oral evaluation for a patient under three years of age |
155 |
155 |
$10K |
| D7140 |
Extraction, erupted tooth or exposed root |
179 |
108 |
$10K |
| D1206 |
Topical application of fluoride varnish |
361 |
361 |
$7K |
| D0274 |
Bitewings - four radiographic images |
247 |
247 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
223 |
220 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
67 |
67 |
$2K |
| D0330 |
Panoramic radiographic image |
66 |
66 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
14 |
12 |
$764.40 |
| D9430 |
|
14 |
13 |
$448.00 |
| D0350 |
|
73 |
27 |
$374.40 |