| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
7,008 |
7,007 |
$250K |
| D1206 |
Topical application of fluoride varnish |
7,942 |
7,924 |
$208K |
| D1351 |
Sealant - per tooth |
5,026 |
1,268 |
$158K |
| D0120 |
Periodic oral evaluation - established patient |
6,829 |
6,828 |
$157K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
949 |
496 |
$83K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,742 |
6,736 |
$75K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,468 |
1,004 |
$71K |
| D0220 |
Intraoral - periapical first radiographic image |
6,623 |
6,621 |
$66K |
| D1110 |
Prophylaxis - adult |
1,263 |
1,263 |
$51K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
755 |
518 |
$44K |
| D0272 |
Bitewings - two radiographic images |
2,972 |
2,972 |
$37K |
| D7140 |
Extraction, erupted tooth or exposed root |
854 |
558 |
$37K |
| D0274 |
Bitewings - four radiographic images |
1,647 |
1,647 |
$30K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
667 |
647 |
$17K |
| D0210 |
Intraoral - complete series of radiographic images |
1,466 |
1,466 |
$15K |
| D0145 |
Oral evaluation for a patient under three years of age |
555 |
555 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
442 |
442 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
527 |
527 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
291 |
291 |
$7K |
| D1354 |
|
388 |
137 |
$6K |
| D7111 |
|
193 |
156 |
$4K |
| D0602 |
|
318 |
318 |
$3K |
| D0330 |
Panoramic radiographic image |
58 |
58 |
$2K |
| D0603 |
|
141 |
141 |
$1K |
| D2335 |
|
14 |
12 |
$1K |
| D9920 |
|
46 |
44 |
$1K |
| D0273 |
|
51 |
51 |
$816.66 |
| D0270 |
|
12 |
12 |
$142.60 |