| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
7,040 |
6,962 |
$186K |
| D1206 |
Topical application of fluoride varnish |
9,184 |
9,074 |
$149K |
| D0120 |
Periodic oral evaluation - established patient |
8,333 |
8,238 |
$126K |
| D1351 |
Sealant - per tooth |
3,032 |
994 |
$80K |
| D9630 |
|
5,253 |
5,183 |
$78K |
| D1110 |
Prophylaxis - adult |
2,198 |
2,167 |
$75K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,182 |
720 |
$75K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,642 |
1,568 |
$41K |
| D7140 |
Extraction, erupted tooth or exposed root |
665 |
340 |
$41K |
| D0272 |
Bitewings - two radiographic images |
1,889 |
1,859 |
$30K |
| D0274 |
Bitewings - four radiographic images |
1,434 |
1,416 |
$29K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
750 |
737 |
$24K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
414 |
323 |
$19K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,202 |
796 |
$18K |
| D0210 |
Intraoral - complete series of radiographic images |
560 |
485 |
$15K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
104 |
31 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
1,670 |
1,631 |
$13K |
| D1354 |
|
1,114 |
370 |
$12K |
| D3120 |
|
720 |
357 |
$12K |
| D0140 |
Limited oral evaluation - problem focused |
167 |
165 |
$3K |
| D9920 |
|
24 |
24 |
$2K |
| D0330 |
Panoramic radiographic image |
39 |
39 |
$1K |
| D0240 |
|
77 |
55 |
$748.47 |