| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,594 |
3,588 |
$158K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
844 |
340 |
$110K |
| D1351 |
Sealant - per tooth |
4,948 |
844 |
$107K |
| D1206 |
Topical application of fluoride varnish |
3,668 |
3,663 |
$95K |
| D0120 |
Periodic oral evaluation - established patient |
2,247 |
2,244 |
$72K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
834 |
451 |
$52K |
| D9920 |
|
984 |
899 |
$27K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,076 |
1,022 |
$25K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
851 |
849 |
$21K |
| D0603 |
|
3,061 |
3,049 |
$20K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
334 |
205 |
$19K |
| D0272 |
Bitewings - two radiographic images |
1,717 |
1,715 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
2,694 |
2,688 |
$16K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,279 |
2,268 |
$10K |
| D0145 |
Oral evaluation for a patient under three years of age |
400 |
398 |
$9K |
| D0274 |
Bitewings - four radiographic images |
614 |
613 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
199 |
198 |
$5K |
| D1110 |
Prophylaxis - adult |
92 |
92 |
$5K |
| D0602 |
|
276 |
274 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
15 |
12 |
$945.00 |
| D0330 |
Panoramic radiographic image |
62 |
61 |
$692.00 |
| D0210 |
Intraoral - complete series of radiographic images |
15 |
15 |
$450.00 |
| D1330 |
|
48 |
47 |
$0.00 |