| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
11,438 |
11,438 |
$390K |
| D0120 |
Periodic oral evaluation - established patient |
14,466 |
14,466 |
$332K |
| D1110 |
Prophylaxis - adult |
6,588 |
6,588 |
$325K |
| D1206 |
Topical application of fluoride varnish |
17,411 |
17,411 |
$281K |
| D0272 |
Bitewings - two radiographic images |
8,888 |
8,888 |
$164K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,484 |
960 |
$142K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,762 |
1,220 |
$135K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,476 |
984 |
$127K |
| D0274 |
Bitewings - four radiographic images |
4,439 |
4,439 |
$122K |
| D0330 |
Panoramic radiographic image |
2,365 |
2,365 |
$115K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,159 |
2,159 |
$85K |
| D1351 |
Sealant - per tooth |
2,812 |
734 |
$82K |
| D0145 |
Oral evaluation for a patient under three years of age |
1,435 |
1,435 |
$65K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,077 |
2,023 |
$63K |
| D0140 |
Limited oral evaluation - problem focused |
1,151 |
1,142 |
$42K |
| D0220 |
Intraoral - periapical first radiographic image |
1,047 |
1,037 |
$13K |
| D1354 |
|
496 |
178 |
$7K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
40 |
25 |
$5K |
| D0240 |
|
185 |
159 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
68 |
50 |
$659.44 |