| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
8,894 |
8,894 |
$310K |
| D0120 |
Periodic oral evaluation - established patient |
10,617 |
10,617 |
$247K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,002 |
1,049 |
$203K |
| D1206 |
Topical application of fluoride varnish |
11,452 |
11,452 |
$187K |
| D0272 |
Bitewings - two radiographic images |
8,891 |
8,891 |
$168K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,045 |
1,220 |
$166K |
| D1110 |
Prophylaxis - adult |
2,709 |
2,709 |
$133K |
| D1351 |
Sealant - per tooth |
3,751 |
1,180 |
$112K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,914 |
2,867 |
$94K |
| D9248 |
|
1,268 |
1,252 |
$88K |
| D0330 |
Panoramic radiographic image |
1,738 |
1,737 |
$80K |
| D7140 |
Extraction, erupted tooth or exposed root |
379 |
198 |
$33K |
| D0240 |
|
994 |
593 |
$18K |
| D0145 |
Oral evaluation for a patient under three years of age |
211 |
211 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
567 |
562 |
$7K |
| D0274 |
Bitewings - four radiographic images |
155 |
155 |
$5K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
36 |
12 |
$4K |
| D1354 |
|
434 |
214 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
103 |
101 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
40 |
40 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
15 |
12 |
$153.39 |