| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,941 |
1,941 |
$102K |
| D0120 |
Periodic oral evaluation - established patient |
1,564 |
1,564 |
$81K |
| D1310 |
|
880 |
880 |
$40K |
| D1351 |
Sealant - per tooth |
912 |
274 |
$35K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
325 |
188 |
$22K |
| D1206 |
Topical application of fluoride varnish |
629 |
629 |
$20K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
460 |
452 |
$18K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,164 |
1,164 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
179 |
179 |
$12K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
101 |
67 |
$12K |
| D0603 |
|
763 |
763 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,741 |
1,418 |
$11K |
| D0274 |
Bitewings - four radiographic images |
495 |
495 |
$11K |
| D0145 |
Oral evaluation for a patient under three years of age |
164 |
163 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
167 |
124 |
$9K |
| D0272 |
Bitewings - two radiographic images |
704 |
704 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
82 |
53 |
$5K |
| D0350 |
|
460 |
256 |
$4K |
| D0330 |
Panoramic radiographic image |
149 |
148 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
277 |
274 |
$3K |
| D1354 |
|
234 |
77 |
$3K |
| D0270 |
|
528 |
528 |
$3K |
| D9430 |
|
65 |
64 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
14 |
14 |
$672.00 |
| D0601 |
|
29 |
29 |
$435.00 |