| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
4,213 |
4,209 |
$142K |
| D1206 |
Topical application of fluoride varnish |
5,871 |
5,862 |
$113K |
| D0120 |
Periodic oral evaluation - established patient |
3,987 |
3,982 |
$94K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
593 |
343 |
$81K |
| D3120 |
|
1,228 |
237 |
$46K |
| D1110 |
Prophylaxis - adult |
999 |
999 |
$43K |
| D0272 |
Bitewings - two radiographic images |
1,315 |
1,313 |
$27K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
777 |
735 |
$24K |
| D1351 |
Sealant - per tooth |
668 |
204 |
$23K |
| D7140 |
Extraction, erupted tooth or exposed root |
219 |
116 |
$20K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
159 |
40 |
$20K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
100 |
61 |
$16K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
63 |
42 |
$7K |
| D0330 |
Panoramic radiographic image |
113 |
112 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
149 |
149 |
$6K |
| D0145 |
Oral evaluation for a patient under three years of age |
148 |
148 |
$5K |
| D0274 |
Bitewings - four radiographic images |
124 |
124 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
279 |
275 |
$3K |
| D9219 |
|
74 |
72 |
$3K |
| D9248 |
|
14 |
14 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
31 |
31 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
14 |
14 |
$166.60 |