| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
6,006 |
6,005 |
$240K |
| D0120 |
Periodic oral evaluation - established patient |
5,956 |
5,955 |
$193K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,574 |
864 |
$189K |
| D1206 |
Topical application of fluoride varnish |
6,161 |
6,158 |
$167K |
| D0272 |
Bitewings - two radiographic images |
2,596 |
2,595 |
$62K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
261 |
158 |
$47K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
430 |
320 |
$38K |
| D1354 |
|
1,215 |
630 |
$32K |
| D1110 |
Prophylaxis - adult |
547 |
547 |
$28K |
| D1351 |
Sealant - per tooth |
796 |
277 |
$24K |
| D0220 |
Intraoral - periapical first radiographic image |
1,046 |
1,034 |
$19K |
| D7140 |
Extraction, erupted tooth or exposed root |
180 |
119 |
$15K |
| D0330 |
Panoramic radiographic image |
185 |
185 |
$14K |
| D0210 |
Intraoral - complete series of radiographic images |
144 |
144 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
188 |
188 |
$11K |
| D0240 |
|
374 |
204 |
$8K |
| D0274 |
Bitewings - four radiographic images |
179 |
179 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
541 |
287 |
$7K |
| D0145 |
Oral evaluation for a patient under three years of age |
98 |
98 |
$4K |
| D9310 |
|
40 |
40 |
$3K |
| D1999 |
|
268 |
237 |
$0.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,046 |
914 |
$0.00 |