| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
4,715 |
4,688 |
$215K |
| D0120 |
Periodic oral evaluation - established patient |
3,254 |
3,236 |
$206K |
| D1310 |
|
2,715 |
2,702 |
$124K |
| D1206 |
Topical application of fluoride varnish |
4,649 |
4,623 |
$92K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
801 |
793 |
$53K |
| D9993 |
|
732 |
732 |
$47K |
| D0603 |
|
2,638 |
2,625 |
$39K |
| D0272 |
Bitewings - two radiographic images |
2,448 |
2,427 |
$28K |
| D0145 |
Oral evaluation for a patient under three years of age |
420 |
417 |
$28K |
| D1351 |
Sealant - per tooth |
687 |
163 |
$25K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,673 |
2,323 |
$24K |
| D1354 |
|
1,407 |
387 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
728 |
707 |
$9K |
| D0350 |
|
792 |
510 |
$9K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
36 |
18 |
$4K |
| D9430 |
|
128 |
121 |
$4K |
| D7111 |
|
34 |
26 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
18 |
15 |
$982.80 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
16 |
14 |
$640.00 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$259.20 |