| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
8,145 |
8,144 |
$509K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,212 |
1,169 |
$473K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,650 |
1,374 |
$437K |
| D7140 |
Extraction, erupted tooth or exposed root |
3,156 |
1,328 |
$394K |
| D0120 |
Periodic oral evaluation - established patient |
8,657 |
8,656 |
$329K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,694 |
1,105 |
$211K |
| D1208 |
Topical application of fluoride, excluding varnish |
7,951 |
7,950 |
$207K |
| D1351 |
Sealant - per tooth |
3,062 |
1,065 |
$168K |
| D0330 |
Panoramic radiographic image |
1,438 |
1,438 |
$143K |
| D0272 |
Bitewings - two radiographic images |
3,548 |
3,547 |
$131K |
| D1110 |
Prophylaxis - adult |
1,061 |
1,061 |
$92K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,167 |
2,148 |
$79K |
| D1206 |
Topical application of fluoride varnish |
1,304 |
1,304 |
$43K |
| D0220 |
Intraoral - periapical first radiographic image |
1,567 |
1,559 |
$33K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
337 |
337 |
$21K |
| D0273 |
|
612 |
612 |
$18K |
| D0140 |
Limited oral evaluation - problem focused |
217 |
217 |
$12K |
| D1515 |
|
28 |
26 |
$10K |
| D1510 |
|
28 |
26 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
234 |
234 |
$6K |
| D1516 |
|
13 |
13 |
$5K |
| D0145 |
Oral evaluation for a patient under three years of age |
12 |
12 |
$450.00 |