| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
11,228 |
11,228 |
$364K |
| D0120 |
Periodic oral evaluation - established patient |
11,730 |
11,729 |
$251K |
| D1351 |
Sealant - per tooth |
4,785 |
2,030 |
$219K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,133 |
1,512 |
$135K |
| D1206 |
Topical application of fluoride varnish |
5,293 |
5,293 |
$126K |
| D1110 |
Prophylaxis - adult |
2,509 |
2,508 |
$102K |
| D1208 |
Topical application of fluoride, excluding varnish |
8,052 |
8,051 |
$95K |
| D0272 |
Bitewings - two radiographic images |
6,306 |
6,305 |
$79K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,692 |
1,315 |
$76K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
452 |
335 |
$52K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,013 |
821 |
$44K |
| D0240 |
|
2,299 |
1,892 |
$43K |
| D0274 |
Bitewings - four radiographic images |
1,740 |
1,740 |
$37K |
| D0330 |
Panoramic radiographic image |
1,149 |
1,149 |
$35K |
| D0220 |
Intraoral - periapical first radiographic image |
2,623 |
2,594 |
$26K |
| D0350 |
|
3,247 |
3,244 |
$24K |
| D0145 |
Oral evaluation for a patient under three years of age |
959 |
959 |
$24K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
683 |
683 |
$16K |
| D0210 |
Intraoral - complete series of radiographic images |
677 |
661 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
731 |
646 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
441 |
440 |
$5K |
| D9310 |
|
12 |
12 |
$574.63 |
| D1354 |
|
38 |
13 |
$570.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
19 |
19 |
$470.00 |
| D9110 |
|
16 |
16 |
$324.52 |