| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,412 |
3,371 |
$112K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
948 |
586 |
$71K |
| D0120 |
Periodic oral evaluation - established patient |
2,727 |
2,706 |
$67K |
| D1206 |
Topical application of fluoride varnish |
2,188 |
2,166 |
$46K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,185 |
1,055 |
$34K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,141 |
1,119 |
$33K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,589 |
1,153 |
$33K |
| D1351 |
Sealant - per tooth |
751 |
245 |
$23K |
| D0220 |
Intraoral - periapical first radiographic image |
1,724 |
1,620 |
$20K |
| D4346 |
|
327 |
323 |
$15K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
247 |
171 |
$15K |
| D0140 |
Limited oral evaluation - problem focused |
662 |
650 |
$14K |
| D1110 |
Prophylaxis - adult |
254 |
251 |
$11K |
| D0272 |
Bitewings - two radiographic images |
607 |
602 |
$10K |
| D0330 |
Panoramic radiographic image |
230 |
227 |
$9K |
| D0210 |
Intraoral - complete series of radiographic images |
129 |
126 |
$7K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
47 |
12 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
44 |
25 |
$2K |
| D0274 |
Bitewings - four radiographic images |
29 |
28 |
$614.39 |
| D0145 |
Oral evaluation for a patient under three years of age |
13 |
13 |
$251.30 |
| D1354 |
|
43 |
12 |
$250.69 |
| D3120 |
|
123 |
89 |
$39.14 |
| D0603 |
|
27 |
27 |
$0.00 |