| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,306 |
1,306 |
$65K |
| D1120 |
Prophylaxis - child |
1,841 |
1,841 |
$64K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,225 |
1,225 |
$48K |
| D0330 |
Panoramic radiographic image |
1,021 |
1,021 |
$45K |
| D0120 |
Periodic oral evaluation - established patient |
1,753 |
1,753 |
$39K |
| D1206 |
Topical application of fluoride varnish |
2,226 |
2,226 |
$36K |
| D0140 |
Limited oral evaluation - problem focused |
815 |
813 |
$29K |
| D0274 |
Bitewings - four radiographic images |
929 |
929 |
$25K |
| D0272 |
Bitewings - two radiographic images |
1,123 |
1,123 |
$21K |
| D7140 |
Extraction, erupted tooth or exposed root |
204 |
133 |
$18K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
81 |
52 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
510 |
503 |
$6K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
70 |
50 |
$5K |
| D1351 |
Sealant - per tooth |
46 |
12 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
79 |
79 |
$1K |
| D0145 |
Oral evaluation for a patient under three years of age |
16 |
16 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
30 |
28 |
$975.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
17 |
12 |
$173.53 |