| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
5,225 |
5,210 |
$141K |
| D0120 |
Periodic oral evaluation - established patient |
5,552 |
5,540 |
$115K |
| D1351 |
Sealant - per tooth |
6,673 |
1,087 |
$104K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,926 |
1,168 |
$80K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
884 |
472 |
$75K |
| D1206 |
Topical application of fluoride varnish |
2,880 |
2,862 |
$62K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
95 |
75 |
$38K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,667 |
2,667 |
$29K |
| D0140 |
Limited oral evaluation - problem focused |
1,345 |
1,315 |
$29K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,303 |
1,301 |
$29K |
| D0603 |
|
3,320 |
3,303 |
$29K |
| D0210 |
Intraoral - complete series of radiographic images |
956 |
956 |
$29K |
| D1110 |
Prophylaxis - adult |
1,175 |
1,175 |
$23K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
619 |
438 |
$22K |
| D0274 |
Bitewings - four radiographic images |
1,442 |
1,436 |
$16K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
964 |
889 |
$16K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
276 |
222 |
$13K |
| D0272 |
Bitewings - two radiographic images |
1,796 |
1,789 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
2,269 |
2,227 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,289 |
1,276 |
$6K |
| D0330 |
Panoramic radiographic image |
262 |
261 |
$6K |
| D4341 |
|
115 |
44 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
90 |
58 |
$4K |
| D9920 |
|
241 |
228 |
$4K |
| D0601 |
|
271 |
271 |
$3K |
| D0602 |
|
81 |
81 |
$814.50 |
| D0240 |
|
44 |
16 |
$315.00 |
| D0191 |
|
14 |
13 |
$195.00 |
| D0270 |
|
15 |
14 |
$60.00 |