| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,960 |
2,791 |
$92K |
| D1351 |
Sealant - per tooth |
3,358 |
468 |
$86K |
| D0120 |
Periodic oral evaluation - established patient |
2,855 |
2,672 |
$62K |
| D0272 |
Bitewings - two radiographic images |
2,398 |
2,236 |
$50K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,097 |
1,940 |
$36K |
| D1206 |
Topical application of fluoride varnish |
1,454 |
1,386 |
$27K |
| D0330 |
Panoramic radiographic image |
500 |
473 |
$22K |
| D1110 |
Prophylaxis - adult |
509 |
490 |
$21K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
663 |
638 |
$19K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
649 |
570 |
$16K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
223 |
129 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
956 |
881 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,119 |
590 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
165 |
89 |
$10K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
80 |
14 |
$10K |
| D0274 |
Bitewings - four radiographic images |
246 |
243 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
83 |
33 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
56 |
52 |
$2K |
| D0240 |
|
43 |
22 |
$673.34 |
| D0145 |
Oral evaluation for a patient under three years of age |
12 |
12 |
$368.88 |