| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,519 |
1,516 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,693 |
814 |
$6K |
| D1206 |
Topical application of fluoride varnish |
1,632 |
1,626 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
364 |
183 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
522 |
522 |
$5K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
157 |
40 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
996 |
993 |
$4K |
| D0272 |
Bitewings - two radiographic images |
770 |
767 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
993 |
984 |
$3K |
| D0330 |
Panoramic radiographic image |
196 |
195 |
$3K |
| D1351 |
Sealant - per tooth |
433 |
138 |
$3K |
| D0274 |
Bitewings - four radiographic images |
306 |
305 |
$1K |
| D1354 |
|
131 |
45 |
$620.40 |
| D9248 |
|
43 |
40 |
$613.71 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
30 |
12 |
$412.62 |
| D0145 |
Oral evaluation for a patient under three years of age |
44 |
44 |
$351.96 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
68 |
65 |
$288.60 |
| D7140 |
Extraction, erupted tooth or exposed root |
57 |
26 |
$223.35 |
| D1110 |
Prophylaxis - adult |
13 |
13 |
$184.84 |
| D0140 |
Limited oral evaluation - problem focused |
25 |
25 |
$100.38 |
| D0603 |
|
397 |
388 |
$0.00 |
| D0601 |
|
80 |
80 |
$0.00 |
| D0602 |
|
12 |
12 |
$0.00 |