| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
4,967 |
4,966 |
$256K |
| D0120 |
Periodic oral evaluation - established patient |
2,497 |
2,496 |
$173K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,017 |
2,017 |
$133K |
| D1351 |
Sealant - per tooth |
2,805 |
841 |
$106K |
| D1310 |
|
2,212 |
2,211 |
$101K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,714 |
4,710 |
$94K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
539 |
340 |
$63K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
810 |
530 |
$54K |
| D0145 |
Oral evaluation for a patient under three years of age |
522 |
522 |
$36K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
666 |
478 |
$35K |
| D7140 |
Extraction, erupted tooth or exposed root |
528 |
371 |
$29K |
| D0230 |
Intraoral - periapical each additional radiographic image |
7,076 |
2,669 |
$28K |
| D0603 |
|
1,857 |
1,855 |
$28K |
| D0274 |
Bitewings - four radiographic images |
1,144 |
1,144 |
$24K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
583 |
525 |
$23K |
| D0272 |
Bitewings - two radiographic images |
1,894 |
1,892 |
$22K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
305 |
211 |
$20K |
| D0330 |
Panoramic radiographic image |
463 |
463 |
$14K |
| D9430 |
|
279 |
275 |
$9K |
| D0350 |
|
756 |
508 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
504 |
499 |
$6K |
| D0601 |
|
323 |
322 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
19 |
15 |
$2K |
| D2160 |
|
19 |
13 |
$2K |
| D1206 |
Topical application of fluoride varnish |
82 |
82 |
$1K |
| D2140 |
|
16 |
12 |
$873.60 |
| D0340 |
|
16 |
16 |
$800.00 |
| D0210 |
Intraoral - complete series of radiographic images |
15 |
15 |
$720.00 |