| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
7,029 |
7,029 |
$243K |
| D0120 |
Periodic oral evaluation - established patient |
6,928 |
6,928 |
$164K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,434 |
932 |
$143K |
| D1206 |
Topical application of fluoride varnish |
8,438 |
8,438 |
$138K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,026 |
345 |
$121K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,413 |
789 |
$112K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,110 |
607 |
$103K |
| D1110 |
Prophylaxis - adult |
2,003 |
2,003 |
$100K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,785 |
1,785 |
$72K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,775 |
1,742 |
$56K |
| D0272 |
Bitewings - two radiographic images |
2,942 |
2,942 |
$56K |
| D0330 |
Panoramic radiographic image |
748 |
748 |
$37K |
| D0220 |
Intraoral - periapical first radiographic image |
2,902 |
2,884 |
$37K |
| D0140 |
Limited oral evaluation - problem focused |
953 |
948 |
$36K |
| D1351 |
Sealant - per tooth |
1,211 |
401 |
$35K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,394 |
1,433 |
$35K |
| D9420 |
|
182 |
182 |
$15K |
| D0240 |
|
998 |
873 |
$15K |
| D9310 |
|
128 |
128 |
$8K |
| D2330 |
|
83 |
40 |
$6K |
| D0145 |
Oral evaluation for a patient under three years of age |
116 |
116 |
$4K |
| D0274 |
Bitewings - four radiographic images |
97 |
97 |
$3K |
| D2332 |
|
22 |
12 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
17 |
17 |
$1K |