| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
13,551 |
13,481 |
$693K |
| D0120 |
Periodic oral evaluation - established patient |
7,774 |
7,767 |
$532K |
| D1310 |
|
7,843 |
7,805 |
$355K |
| D1206 |
Topical application of fluoride varnish |
13,338 |
13,270 |
$282K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,962 |
3,911 |
$264K |
| D0230 |
Intraoral - periapical each additional radiographic image |
40,728 |
10,214 |
$172K |
| D0603 |
|
7,691 |
7,654 |
$113K |
| D0145 |
Oral evaluation for a patient under three years of age |
1,597 |
1,585 |
$109K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,404 |
2,222 |
$95K |
| D1351 |
Sealant - per tooth |
2,151 |
679 |
$80K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,139 |
726 |
$74K |
| D0274 |
Bitewings - four radiographic images |
2,356 |
2,347 |
$49K |
| D0220 |
Intraoral - periapical first radiographic image |
3,966 |
3,925 |
$47K |
| D1354 |
|
5,244 |
1,323 |
$46K |
| D0350 |
|
4,258 |
2,003 |
$46K |
| D0272 |
Bitewings - two radiographic images |
3,905 |
3,876 |
$44K |
| D9430 |
|
914 |
877 |
$29K |
| D7140 |
Extraction, erupted tooth or exposed root |
389 |
259 |
$22K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
111 |
84 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
124 |
93 |
$6K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
17 |
12 |
$2K |
| D0602 |
|
22 |
22 |
$330.00 |
| D0270 |
|
13 |
13 |
$65.00 |
| D4346 |
|
26 |
26 |
$0.00 |