| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
7,132 |
7,132 |
$276K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,410 |
1,612 |
$217K |
| D0120 |
Periodic oral evaluation - established patient |
5,954 |
5,954 |
$216K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
3,162 |
2,829 |
$181K |
| D1206 |
Topical application of fluoride varnish |
6,972 |
6,972 |
$137K |
| D0272 |
Bitewings - two radiographic images |
3,791 |
3,790 |
$99K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
667 |
339 |
$70K |
| D0274 |
Bitewings - four radiographic images |
1,052 |
1,052 |
$56K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
557 |
427 |
$47K |
| D1351 |
Sealant - per tooth |
890 |
443 |
$39K |
| D1354 |
|
2,684 |
902 |
$22K |
| D0140 |
Limited oral evaluation - problem focused |
509 |
502 |
$19K |
| D0220 |
Intraoral - periapical first radiographic image |
1,054 |
1,041 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
409 |
409 |
$16K |
| D0330 |
Panoramic radiographic image |
114 |
114 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
264 |
200 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
57 |
41 |
$4K |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$738.84 |
| D0145 |
Oral evaluation for a patient under three years of age |
12 |
12 |
$457.68 |