| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,530 |
2,527 |
$101K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
666 |
187 |
$73K |
| D0120 |
Periodic oral evaluation - established patient |
1,754 |
1,754 |
$49K |
| D1206 |
Topical application of fluoride varnish |
2,435 |
2,432 |
$46K |
| D1351 |
Sealant - per tooth |
687 |
215 |
$22K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,218 |
568 |
$19K |
| D0272 |
Bitewings - two radiographic images |
952 |
952 |
$17K |
| D0603 |
|
2,304 |
2,296 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
337 |
337 |
$13K |
| D0145 |
Oral evaluation for a patient under three years of age |
381 |
380 |
$10K |
| D0240 |
|
639 |
378 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
765 |
736 |
$10K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
355 |
348 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
125 |
81 |
$9K |
| D2929 |
|
54 |
15 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
64 |
64 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
40 |
31 |
$2K |
| D1354 |
|
163 |
74 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
37 |
33 |
$1K |
| D1110 |
Prophylaxis - adult |
16 |
16 |
$864.80 |
| D0330 |
Panoramic radiographic image |
87 |
87 |
$647.40 |
| D0274 |
Bitewings - four radiographic images |
26 |
26 |
$633.65 |
| D0602 |
|
91 |
90 |
$431.75 |
| D1330 |
|
1,620 |
1,618 |
$0.09 |
| D1310 |
|
1,619 |
1,618 |
$0.06 |