| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
11,374 |
11,363 |
$392K |
| D1206 |
Topical application of fluoride varnish |
11,991 |
11,979 |
$196K |
| D0145 |
Oral evaluation for a patient under three years of age |
3,063 |
3,060 |
$158K |
| D0120 |
Periodic oral evaluation - established patient |
6,346 |
6,340 |
$148K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,472 |
3,467 |
$142K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,025 |
356 |
$130K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,207 |
680 |
$120K |
| D0240 |
|
6,586 |
3,494 |
$116K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
3,587 |
3,362 |
$112K |
| D7140 |
Extraction, erupted tooth or exposed root |
892 |
515 |
$81K |
| D0272 |
Bitewings - two radiographic images |
4,183 |
4,178 |
$77K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
672 |
411 |
$52K |
| D1351 |
Sealant - per tooth |
1,796 |
624 |
$51K |
| D0330 |
Panoramic radiographic image |
851 |
851 |
$42K |
| D1110 |
Prophylaxis - adult |
645 |
643 |
$30K |
| D9248 |
|
390 |
366 |
$27K |
| D0220 |
Intraoral - periapical first radiographic image |
2,074 |
2,037 |
$25K |
| D0140 |
Limited oral evaluation - problem focused |
320 |
317 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,156 |
525 |
$9K |
| D9420 |
|
70 |
70 |
$6K |
| D9920 |
|
84 |
84 |
$5K |
| D0274 |
Bitewings - four radiographic images |
28 |
28 |
$613.00 |
| D1354 |
|
31 |
12 |
$465.00 |
| D0270 |
|
12 |
12 |
$146.59 |