| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
4,352 |
4,339 |
$175K |
| D1206 |
Topical application of fluoride varnish |
5,908 |
5,877 |
$139K |
| D0120 |
Periodic oral evaluation - established patient |
4,870 |
4,848 |
$130K |
| D0272 |
Bitewings - two radiographic images |
1,842 |
1,839 |
$40K |
| D0350 |
|
692 |
684 |
$39K |
| D1110 |
Prophylaxis - adult |
643 |
638 |
$38K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
308 |
177 |
$30K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
211 |
57 |
$27K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
214 |
114 |
$26K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
553 |
553 |
$24K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
636 |
618 |
$21K |
| D0240 |
|
516 |
516 |
$19K |
| D7140 |
Extraction, erupted tooth or exposed root |
165 |
84 |
$17K |
| D1351 |
Sealant - per tooth |
321 |
121 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
814 |
804 |
$11K |
| D1354 |
|
246 |
79 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
234 |
232 |
$5K |
| D0330 |
Panoramic radiographic image |
76 |
76 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
75 |
72 |
$3K |
| D0274 |
Bitewings - four radiographic images |
85 |
82 |
$3K |
| D0145 |
Oral evaluation for a patient under three years of age |
44 |
44 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
42 |
41 |
$822.81 |
| D9219 |
|
12 |
12 |
$515.64 |