| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
5,226 |
5,201 |
$186K |
| D0120 |
Periodic oral evaluation - established patient |
5,394 |
5,370 |
$152K |
| D0145 |
Oral evaluation for a patient under three years of age |
1,074 |
1,066 |
$149K |
| D1351 |
Sealant - per tooth |
4,742 |
807 |
$128K |
| D0272 |
Bitewings - two radiographic images |
3,849 |
3,828 |
$86K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
534 |
176 |
$70K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,992 |
3,982 |
$57K |
| D1110 |
Prophylaxis - adult |
1,064 |
1,057 |
$56K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
611 |
331 |
$56K |
| D9248 |
|
330 |
322 |
$37K |
| D0274 |
Bitewings - four radiographic images |
1,110 |
1,105 |
$36K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,018 |
1,007 |
$35K |
| D0330 |
Panoramic radiographic image |
967 |
959 |
$34K |
| D1206 |
Topical application of fluoride varnish |
2,301 |
2,282 |
$33K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,865 |
1,168 |
$29K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
984 |
957 |
$25K |
| D0220 |
Intraoral - periapical first radiographic image |
1,824 |
1,787 |
$20K |
| D0210 |
Intraoral - complete series of radiographic images |
118 |
118 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
81 |
56 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
257 |
250 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
78 |
39 |
$5K |
| D0350 |
|
14 |
13 |
$238.94 |
| D0240 |
|
23 |
12 |
$196.00 |
| D1330 |
|
16 |
15 |
$122.50 |
| D0603 |
|
7,499 |
7,439 |
$0.00 |
| D0601 |
|
17 |
17 |
$0.00 |