| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,005 |
3,005 |
$92K |
| D0120 |
Periodic oral evaluation - established patient |
3,063 |
3,063 |
$63K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,033 |
745 |
$52K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,767 |
3,767 |
$41K |
| D0272 |
Bitewings - two radiographic images |
2,663 |
2,663 |
$32K |
| D1110 |
Prophylaxis - adult |
785 |
785 |
$31K |
| D1351 |
Sealant - per tooth |
931 |
342 |
$30K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
736 |
552 |
$24K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
331 |
281 |
$24K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
622 |
622 |
$13K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
339 |
321 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
925 |
920 |
$9K |
| D0274 |
Bitewings - four radiographic images |
422 |
422 |
$9K |
| D7140 |
Extraction, erupted tooth or exposed root |
275 |
211 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
620 |
620 |
$4K |
| D9310 |
|
63 |
63 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
186 |
185 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
59 |
59 |
$1K |
| D0340 |
|
30 |
30 |
$1K |
| D1354 |
|
85 |
28 |
$1K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
16 |
14 |
$1K |
| D0330 |
Panoramic radiographic image |
25 |
25 |
$722.15 |
| D0350 |
|
44 |
44 |
$458.02 |
| D1320 |
|
14 |
14 |
$112.00 |