| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
11,897 |
11,750 |
$327K |
| D1206 |
Topical application of fluoride varnish |
13,649 |
13,486 |
$234K |
| D0120 |
Periodic oral evaluation - established patient |
10,484 |
10,348 |
$170K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
640 |
226 |
$72K |
| D0274 |
Bitewings - four radiographic images |
3,103 |
3,070 |
$70K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,238 |
2,149 |
$61K |
| D1110 |
Prophylaxis - adult |
1,440 |
1,417 |
$50K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,769 |
1,750 |
$48K |
| D7140 |
Extraction, erupted tooth or exposed root |
535 |
249 |
$27K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
505 |
291 |
$24K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
338 |
193 |
$21K |
| D0272 |
Bitewings - two radiographic images |
1,311 |
1,292 |
$20K |
| D1351 |
Sealant - per tooth |
1,107 |
371 |
$19K |
| D0220 |
Intraoral - periapical first radiographic image |
1,460 |
1,427 |
$11K |
| D0145 |
Oral evaluation for a patient under three years of age |
291 |
290 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
251 |
249 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
632 |
279 |
$4K |
| D0330 |
Panoramic radiographic image |
62 |
56 |
$2K |
| D0240 |
|
136 |
100 |
$1K |
| D3120 |
|
77 |
53 |
$1K |
| D9310 |
|
14 |
14 |
$0.00 |
| D9630 |
|
43 |
43 |
$0.00 |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$0.00 |