| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,324 |
2,324 |
$67K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
716 |
345 |
$61K |
| D0230 |
Intraoral - periapical each additional radiographic image |
8,386 |
2,981 |
$60K |
| D0120 |
Periodic oral evaluation - established patient |
2,524 |
2,524 |
$50K |
| D0220 |
Intraoral - periapical first radiographic image |
3,402 |
3,362 |
$49K |
| D1110 |
Prophylaxis - adult |
716 |
716 |
$29K |
| D1206 |
Topical application of fluoride varnish |
1,796 |
1,796 |
$26K |
| D0330 |
Panoramic radiographic image |
537 |
537 |
$24K |
| D0274 |
Bitewings - four radiographic images |
800 |
800 |
$22K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
382 |
210 |
$20K |
| D0140 |
Limited oral evaluation - problem focused |
708 |
697 |
$20K |
| D9248 |
|
151 |
143 |
$19K |
| D0240 |
|
1,080 |
554 |
$19K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,281 |
1,281 |
$17K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
455 |
427 |
$11K |
| D1351 |
Sealant - per tooth |
462 |
145 |
$11K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
88 |
31 |
$10K |
| D7140 |
Extraction, erupted tooth or exposed root |
130 |
39 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
269 |
269 |
$8K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
44 |
28 |
$5K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
21 |
12 |
$3K |
| D0272 |
Bitewings - two radiographic images |
145 |
145 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
15 |
15 |
$457.50 |
| D9610 |
|
13 |
13 |
$396.50 |
| D0350 |
|
13 |
13 |
$319.55 |