| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,965 |
3,933 |
$175K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
414 |
244 |
$52K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
524 |
308 |
$41K |
| D1110 |
Prophylaxis - adult |
659 |
652 |
$26K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,101 |
2,779 |
$23K |
| D0120 |
Periodic oral evaluation - established patient |
4,032 |
3,991 |
$20K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
365 |
362 |
$15K |
| D7140 |
Extraction, erupted tooth or exposed root |
387 |
196 |
$15K |
| D1206 |
Topical application of fluoride varnish |
4,689 |
4,643 |
$15K |
| D0330 |
Panoramic radiographic image |
122 |
121 |
$13K |
| D1354 |
|
749 |
301 |
$13K |
| D0274 |
Bitewings - four radiographic images |
1,860 |
1,830 |
$13K |
| D1351 |
Sealant - per tooth |
1,821 |
462 |
$8K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
736 |
648 |
$6K |
| D1330 |
|
3,741 |
3,710 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
3,387 |
3,264 |
$4K |
| D0272 |
Bitewings - two radiographic images |
1,149 |
1,140 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
29 |
24 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
39 |
38 |
$600.24 |
| D1208 |
Topical application of fluoride, excluding varnish |
34 |
34 |
$267.55 |
| D0210 |
Intraoral - complete series of radiographic images |
14 |
14 |
$247.56 |
| D0145 |
Oral evaluation for a patient under three years of age |
16 |
16 |
$186.02 |