| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
17,251 |
17,248 |
$605K |
| D0120 |
Periodic oral evaluation - established patient |
21,006 |
21,004 |
$495K |
| D1208 |
Topical application of fluoride, excluding varnish |
22,746 |
22,743 |
$374K |
| D0272 |
Bitewings - two radiographic images |
16,807 |
16,806 |
$319K |
| D1110 |
Prophylaxis - adult |
5,969 |
5,969 |
$303K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,461 |
1,801 |
$263K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,011 |
1,022 |
$259K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,285 |
1,547 |
$200K |
| D0330 |
Panoramic radiographic image |
3,681 |
3,681 |
$170K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
4,853 |
4,757 |
$159K |
| D1351 |
Sealant - per tooth |
4,665 |
1,455 |
$141K |
| D7140 |
Extraction, erupted tooth or exposed root |
779 |
482 |
$84K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,234 |
1,234 |
$52K |
| D0240 |
|
2,459 |
2,011 |
$46K |
| D0140 |
Limited oral evaluation - problem focused |
1,143 |
1,134 |
$44K |
| D0220 |
Intraoral - periapical first radiographic image |
1,285 |
1,273 |
$17K |
| D0274 |
Bitewings - four radiographic images |
523 |
523 |
$15K |
| D0145 |
Oral evaluation for a patient under three years of age |
264 |
263 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
92 |
54 |
$1K |
| D1354 |
|
80 |
30 |
$970.00 |