| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,016 |
2,015 |
$75K |
| D0120 |
Periodic oral evaluation - established patient |
2,173 |
2,171 |
$54K |
| D1206 |
Topical application of fluoride varnish |
2,158 |
2,157 |
$48K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
596 |
580 |
$32K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
224 |
93 |
$27K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
350 |
243 |
$26K |
| D1110 |
Prophylaxis - adult |
347 |
347 |
$16K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
216 |
177 |
$13K |
| D0272 |
Bitewings - two radiographic images |
643 |
641 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
356 |
356 |
$9K |
| D7140 |
Extraction, erupted tooth or exposed root |
105 |
59 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
352 |
350 |
$8K |
| D0274 |
Bitewings - four radiographic images |
232 |
232 |
$7K |
| D0240 |
|
362 |
172 |
$4K |
| D1351 |
Sealant - per tooth |
42 |
15 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
120 |
117 |
$1K |
| D0145 |
Oral evaluation for a patient under three years of age |
46 |
46 |
$950.48 |
| D0210 |
Intraoral - complete series of radiographic images |
18 |
18 |
$922.25 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$170.75 |
| D0230 |
Intraoral - periapical each additional radiographic image |
25 |
12 |
$108.00 |