| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
8,818 |
8,818 |
$347K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,132 |
2,012 |
$311K |
| D0120 |
Periodic oral evaluation - established patient |
9,765 |
9,765 |
$268K |
| D1206 |
Topical application of fluoride varnish |
9,132 |
9,132 |
$254K |
| D1354 |
|
5,377 |
1,067 |
$197K |
| D1351 |
Sealant - per tooth |
4,356 |
1,383 |
$160K |
| D1110 |
Prophylaxis - adult |
2,644 |
2,644 |
$141K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,226 |
983 |
$105K |
| D0330 |
Panoramic radiographic image |
1,388 |
1,388 |
$71K |
| D0272 |
Bitewings - two radiographic images |
2,725 |
2,725 |
$56K |
| D0274 |
Bitewings - four radiographic images |
1,110 |
1,110 |
$41K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,803 |
2,803 |
$40K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,339 |
1,339 |
$38K |
| D7140 |
Extraction, erupted tooth or exposed root |
717 |
510 |
$35K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
328 |
295 |
$34K |
| D0220 |
Intraoral - periapical first radiographic image |
896 |
868 |
$11K |
| D0145 |
Oral evaluation for a patient under three years of age |
336 |
336 |
$9K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
45 |
35 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
26 |
26 |
$432.25 |
| D0240 |
|
24 |
24 |
$371.45 |
| D9110 |
|
12 |
12 |
$333.48 |
| D3110 |
|
14 |
14 |
$180.57 |