| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,402 |
3,336 |
$204K |
| D1110 |
Prophylaxis - adult |
1,376 |
1,366 |
$108K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,470 |
760 |
$93K |
| D0330 |
Panoramic radiographic image |
496 |
486 |
$37K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
478 |
338 |
$26K |
| D1351 |
Sealant - per tooth |
4,733 |
1,339 |
$25K |
| D7140 |
Extraction, erupted tooth or exposed root |
452 |
238 |
$17K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
279 |
277 |
$15K |
| D1206 |
Topical application of fluoride varnish |
4,458 |
4,388 |
$8K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
77 |
40 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
4,063 |
4,016 |
$6K |
| D0272 |
Bitewings - two radiographic images |
2,590 |
2,533 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
136 |
134 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,153 |
1,078 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
14 |
14 |
$2K |
| D2331 |
|
25 |
13 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
821 |
790 |
$1K |
| D0274 |
Bitewings - four radiographic images |
984 |
978 |
$868.92 |
| D0240 |
|
384 |
290 |
$702.60 |
| D1354 |
|
67 |
26 |
$392.17 |
| D0230 |
Intraoral - periapical each additional radiographic image |
180 |
114 |
$95.55 |
| D0145 |
Oral evaluation for a patient under three years of age |
25 |
25 |
$80.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
26 |
26 |
$40.00 |