| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,935 |
2,913 |
$113K |
| D1351 |
Sealant - per tooth |
2,799 |
787 |
$90K |
| D1206 |
Topical application of fluoride varnish |
3,627 |
3,589 |
$65K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,736 |
1,726 |
$64K |
| D0120 |
Periodic oral evaluation - established patient |
1,473 |
1,468 |
$39K |
| D1354 |
|
2,430 |
1,091 |
$35K |
| D1110 |
Prophylaxis - adult |
688 |
686 |
$31K |
| D0272 |
Bitewings - two radiographic images |
917 |
913 |
$17K |
| D9630 |
|
787 |
783 |
$14K |
| D0274 |
Bitewings - four radiographic images |
511 |
507 |
$14K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
111 |
43 |
$10K |
| D0603 |
|
888 |
885 |
$8K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
286 |
268 |
$7K |
| D1330 |
|
705 |
694 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
61 |
34 |
$4K |
| D0602 |
|
426 |
425 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
46 |
27 |
$3K |
| D0601 |
|
327 |
327 |
$2K |
| D1999 |
|
342 |
321 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
65 |
62 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
33 |
26 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
30 |
29 |
$762.50 |
| D0330 |
Panoramic radiographic image |
18 |
18 |
$688.00 |
| D0240 |
|
46 |
26 |
$646.00 |
| D0220 |
Intraoral - periapical first radiographic image |
13 |
13 |
$141.00 |