| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
6,020 |
6,020 |
$209K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,250 |
852 |
$133K |
| D0120 |
Periodic oral evaluation - established patient |
5,023 |
5,023 |
$118K |
| D1206 |
Topical application of fluoride varnish |
7,007 |
7,007 |
$116K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,323 |
2,173 |
$74K |
| D1110 |
Prophylaxis - adult |
1,471 |
1,471 |
$72K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,598 |
1,598 |
$68K |
| D0145 |
Oral evaluation for a patient under three years of age |
960 |
960 |
$60K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
375 |
217 |
$51K |
| D0272 |
Bitewings - two radiographic images |
2,330 |
2,330 |
$44K |
| D7140 |
Extraction, erupted tooth or exposed root |
365 |
226 |
$44K |
| D0210 |
Intraoral - complete series of radiographic images |
586 |
586 |
$36K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
204 |
166 |
$22K |
| D1351 |
Sealant - per tooth |
504 |
144 |
$15K |
| D0274 |
Bitewings - four radiographic images |
523 |
523 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
1,040 |
1,033 |
$14K |
| D9248 |
|
143 |
141 |
$13K |
| D0140 |
Limited oral evaluation - problem focused |
338 |
330 |
$13K |
| D0330 |
Panoramic radiographic image |
68 |
67 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
51 |
42 |
$585.39 |