| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
4,115 |
4,073 |
$19K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
769 |
186 |
$16K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,613 |
761 |
$15K |
| D1206 |
Topical application of fluoride varnish |
2,935 |
2,922 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,258 |
1,651 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,042 |
1,036 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
3,479 |
3,426 |
$7K |
| D0272 |
Bitewings - two radiographic images |
2,371 |
2,337 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
2,272 |
2,230 |
$5K |
| D1351 |
Sealant - per tooth |
1,367 |
472 |
$4K |
| D0330 |
Panoramic radiographic image |
561 |
550 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
224 |
96 |
$3K |
| D0274 |
Bitewings - four radiographic images |
1,025 |
1,006 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
351 |
225 |
$2K |
| D1354 |
|
490 |
140 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
219 |
218 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
675 |
630 |
$1K |
| D0350 |
|
192 |
189 |
$1K |
| D1110 |
Prophylaxis - adult |
518 |
504 |
$749.52 |
| D1208 |
Topical application of fluoride, excluding varnish |
2,078 |
2,024 |
$306.00 |
| D0140 |
Limited oral evaluation - problem focused |
30 |
29 |
$205.44 |
| D0210 |
Intraoral - complete series of radiographic images |
174 |
174 |
$107.07 |
| D9248 |
|
27 |
26 |
$69.79 |
| D1999 |
|
130 |
129 |
$0.00 |
| D0603 |
|
561 |
537 |
$0.00 |
| D0601 |
|
167 |
166 |
$0.00 |
| D0240 |
|
175 |
99 |
$0.00 |
| D0602 |
|
14 |
14 |
$0.00 |