| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
507 |
489 |
$16K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
194 |
135 |
$13K |
| D7140 |
Extraction, erupted tooth or exposed root |
246 |
138 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
194 |
142 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
461 |
452 |
$10K |
| D1351 |
Sealant - per tooth |
434 |
131 |
$10K |
| D1110 |
Prophylaxis - adult |
272 |
262 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
433 |
419 |
$9K |
| D1206 |
Topical application of fluoride varnish |
305 |
289 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
173 |
121 |
$7K |
| D0274 |
Bitewings - four radiographic images |
368 |
359 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
927 |
604 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
750 |
721 |
$4K |
| D2332 |
|
45 |
28 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
44 |
34 |
$3K |
| D0330 |
Panoramic radiographic image |
118 |
118 |
$2K |
| D0272 |
Bitewings - two radiographic images |
166 |
164 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
247 |
247 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
96 |
94 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
14 |
13 |
$923.52 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
13 |
13 |
$176.28 |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$31.90 |
| D0602 |
|
45 |
45 |
$0.00 |
| D0603 |
|
246 |
246 |
$0.00 |