| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
6,244 |
6,244 |
$313K |
| D1120 |
Prophylaxis - child |
8,657 |
8,657 |
$301K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
3,536 |
2,273 |
$282K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,531 |
1,598 |
$257K |
| D0120 |
Periodic oral evaluation - established patient |
10,926 |
10,926 |
$252K |
| D1206 |
Topical application of fluoride varnish |
14,895 |
14,895 |
$242K |
| D0272 |
Bitewings - two radiographic images |
12,121 |
12,121 |
$229K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
5,551 |
5,474 |
$179K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,468 |
3,468 |
$140K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,104 |
589 |
$138K |
| D0330 |
Panoramic radiographic image |
2,697 |
2,697 |
$120K |
| D7140 |
Extraction, erupted tooth or exposed root |
991 |
681 |
$85K |
| D0140 |
Limited oral evaluation - problem focused |
1,214 |
1,204 |
$47K |
| D0220 |
Intraoral - periapical first radiographic image |
1,160 |
1,140 |
$15K |
| D0145 |
Oral evaluation for a patient under three years of age |
208 |
208 |
$8K |
| D7111 |
|
12 |
12 |
$804.00 |