| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,572 |
1,572 |
$70K |
| D0120 |
Periodic oral evaluation - established patient |
1,804 |
1,804 |
$53K |
| D1110 |
Prophylaxis - adult |
650 |
650 |
$38K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
418 |
245 |
$34K |
| D1351 |
Sealant - per tooth |
722 |
219 |
$31K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,830 |
1,828 |
$27K |
| D1206 |
Topical application of fluoride varnish |
715 |
715 |
$22K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,473 |
1,473 |
$21K |
| D0220 |
Intraoral - periapical first radiographic image |
1,428 |
1,426 |
$21K |
| D0272 |
Bitewings - two radiographic images |
1,147 |
1,147 |
$20K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
131 |
103 |
$16K |
| D0274 |
Bitewings - four radiographic images |
434 |
434 |
$13K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
318 |
300 |
$12K |
| D7140 |
Extraction, erupted tooth or exposed root |
135 |
96 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
217 |
217 |
$6K |
| D0145 |
Oral evaluation for a patient under three years of age |
123 |
123 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
34 |
32 |
$3K |
| D9310 |
|
21 |
21 |
$2K |
| D0330 |
Panoramic radiographic image |
30 |
30 |
$1K |
| D0270 |
|
56 |
56 |
$792.96 |
| D0273 |
|
30 |
30 |
$594.28 |
| D0210 |
Intraoral - complete series of radiographic images |
44 |
44 |
$532.40 |
| D0140 |
Limited oral evaluation - problem focused |
36 |
36 |
$510.30 |
| D0240 |
|
22 |
14 |
$436.10 |