| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,350 |
1,350 |
$81K |
| D0120 |
Periodic oral evaluation - established patient |
1,030 |
1,030 |
$68K |
| D1206 |
Topical application of fluoride varnish |
1,416 |
1,416 |
$51K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
156 |
115 |
$33K |
| D1354 |
|
1,486 |
351 |
$27K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
270 |
252 |
$23K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
256 |
256 |
$21K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
123 |
86 |
$19K |
| D0272 |
Bitewings - two radiographic images |
572 |
572 |
$16K |
| D1110 |
Prophylaxis - adult |
131 |
131 |
$14K |
| D1351 |
Sealant - per tooth |
250 |
101 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
660 |
649 |
$11K |
| D0274 |
Bitewings - four radiographic images |
154 |
154 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
607 |
571 |
$8K |
| D0240 |
|
218 |
117 |
$8K |
| D0603 |
|
745 |
744 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
49 |
32 |
$7K |
| D0330 |
Panoramic radiographic image |
84 |
84 |
$7K |
| D0145 |
Oral evaluation for a patient under three years of age |
91 |
91 |
$6K |
| D1355 |
|
774 |
164 |
$6K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
17 |
12 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
59 |
58 |
$4K |
| D0602 |
|
152 |
152 |
$990.00 |