| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
7,482 |
7,032 |
$208K |
| D1206 |
Topical application of fluoride varnish |
6,436 |
6,060 |
$158K |
| D0120 |
Periodic oral evaluation - established patient |
7,936 |
7,483 |
$152K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,017 |
652 |
$108K |
| D0230 |
Intraoral - periapical each additional radiographic image |
11,808 |
3,530 |
$95K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,068 |
748 |
$83K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,814 |
2,510 |
$66K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
988 |
734 |
$65K |
| D0330 |
Panoramic radiographic image |
1,387 |
1,282 |
$59K |
| D0220 |
Intraoral - periapical first radiographic image |
5,433 |
5,037 |
$56K |
| D0272 |
Bitewings - two radiographic images |
3,622 |
3,407 |
$53K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,166 |
2,940 |
$44K |
| D1999 |
|
2,667 |
1,953 |
$40K |
| D1351 |
Sealant - per tooth |
1,718 |
511 |
$39K |
| D7140 |
Extraction, erupted tooth or exposed root |
508 |
317 |
$28K |
| D0140 |
Limited oral evaluation - problem focused |
788 |
704 |
$21K |
| D1354 |
|
702 |
267 |
$20K |
| D1110 |
Prophylaxis - adult |
460 |
419 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
620 |
539 |
$16K |
| D0274 |
Bitewings - four radiographic images |
409 |
371 |
$8K |
| D0145 |
Oral evaluation for a patient under three years of age |
295 |
270 |
$7K |
| D3120 |
|
39 |
26 |
$856.00 |