| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
5,963 |
5,963 |
$203K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,628 |
919 |
$158K |
| D0120 |
Periodic oral evaluation - established patient |
5,814 |
5,814 |
$133K |
| D1206 |
Topical application of fluoride varnish |
8,059 |
8,059 |
$129K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
981 |
333 |
$120K |
| D1110 |
Prophylaxis - adult |
1,837 |
1,837 |
$89K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,369 |
2,205 |
$75K |
| D0272 |
Bitewings - two radiographic images |
3,922 |
3,922 |
$72K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
821 |
557 |
$65K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,432 |
1,432 |
$57K |
| D7140 |
Extraction, erupted tooth or exposed root |
650 |
330 |
$55K |
| D0274 |
Bitewings - four radiographic images |
1,422 |
1,422 |
$34K |
| D0220 |
Intraoral - periapical first radiographic image |
2,502 |
2,487 |
$32K |
| D0330 |
Panoramic radiographic image |
782 |
782 |
$30K |
| D1351 |
Sealant - per tooth |
686 |
220 |
$20K |
| D0140 |
Limited oral evaluation - problem focused |
456 |
455 |
$17K |
| D0145 |
Oral evaluation for a patient under three years of age |
209 |
209 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
508 |
365 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
19 |
13 |
$2K |
| D0240 |
|
12 |
12 |
$203.94 |