| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
9,927 |
9,925 |
$283K |
| D0120 |
Periodic oral evaluation - established patient |
8,800 |
8,800 |
$244K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,478 |
2,034 |
$179K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,502 |
2,166 |
$142K |
| D1206 |
Topical application of fluoride varnish |
9,135 |
9,135 |
$120K |
| D0230 |
Intraoral - periapical each additional radiographic image |
9,113 |
4,846 |
$80K |
| D0272 |
Bitewings - two radiographic images |
4,001 |
4,000 |
$75K |
| D0220 |
Intraoral - periapical first radiographic image |
5,033 |
5,022 |
$59K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
806 |
622 |
$51K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
564 |
230 |
$44K |
| D0274 |
Bitewings - four radiographic images |
951 |
950 |
$30K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
950 |
950 |
$28K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
596 |
391 |
$26K |
| D0140 |
Limited oral evaluation - problem focused |
816 |
790 |
$24K |
| D1110 |
Prophylaxis - adult |
443 |
443 |
$18K |
| D0330 |
Panoramic radiographic image |
198 |
198 |
$11K |
| D0145 |
Oral evaluation for a patient under three years of age |
287 |
287 |
$8K |
| D1351 |
Sealant - per tooth |
202 |
69 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
125 |
76 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,130 |
1,130 |
$5K |
| D9985 |
|
782 |
727 |
$0.00 |