| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
3,086 |
3,086 |
$112K |
| D0274 |
Bitewings - four radiographic images |
2,117 |
2,117 |
$88K |
| D1120 |
Prophylaxis - child |
2,484 |
2,484 |
$81K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,487 |
3,197 |
$75K |
| D0220 |
Intraoral - periapical first radiographic image |
3,788 |
3,746 |
$59K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
781 |
474 |
$51K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
872 |
776 |
$49K |
| D1110 |
Prophylaxis - adult |
946 |
946 |
$46K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
413 |
236 |
$39K |
| D0330 |
Panoramic radiographic image |
498 |
498 |
$36K |
| D1206 |
Topical application of fluoride varnish |
1,803 |
1,803 |
$29K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
446 |
257 |
$29K |
| D0140 |
Limited oral evaluation - problem focused |
632 |
621 |
$23K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
326 |
200 |
$19K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
148 |
89 |
$19K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,430 |
1,430 |
$17K |
| D0272 |
Bitewings - two radiographic images |
673 |
673 |
$17K |
| D7140 |
Extraction, erupted tooth or exposed root |
233 |
158 |
$16K |
| D7240 |
Removal of impacted tooth - completely bony |
42 |
13 |
$13K |
| D2160 |
|
130 |
87 |
$10K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
61 |
39 |
$9K |
| D1351 |
Sealant - per tooth |
185 |
89 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
179 |
179 |
$7K |
| D0145 |
Oral evaluation for a patient under three years of age |
148 |
148 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
76 |
76 |
$5K |
| D1354 |
|
527 |
118 |
$4K |
| D2140 |
|
64 |
32 |
$3K |
| D9110 |
|
14 |
12 |
$834.12 |