| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
4,109 |
4,044 |
$128K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
894 |
361 |
$105K |
| D1206 |
Topical application of fluoride varnish |
5,140 |
5,050 |
$91K |
| D0120 |
Periodic oral evaluation - established patient |
4,022 |
3,950 |
$85K |
| D1351 |
Sealant - per tooth |
2,997 |
813 |
$75K |
| D1110 |
Prophylaxis - adult |
725 |
714 |
$29K |
| D0274 |
Bitewings - four radiographic images |
1,328 |
1,316 |
$25K |
| D0210 |
Intraoral - complete series of radiographic images |
448 |
446 |
$24K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
554 |
549 |
$15K |
| D0330 |
Panoramic radiographic image |
776 |
765 |
$15K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
224 |
162 |
$15K |
| D0272 |
Bitewings - two radiographic images |
579 |
571 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
790 |
763 |
$8K |
| D1354 |
|
799 |
247 |
$5K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
143 |
130 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
40 |
27 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
55 |
54 |
$2K |
| D1353 |
|
66 |
26 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
13 |
13 |
$1K |
| D0190 |
|
88 |
79 |
$1K |
| D0145 |
Oral evaluation for a patient under three years of age |
26 |
26 |
$797.30 |
| D9410 |
|
28 |
26 |
$585.26 |
| D0230 |
Intraoral - periapical each additional radiographic image |
126 |
49 |
$576.00 |