| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
740 |
704 |
$23K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
218 |
116 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
783 |
751 |
$20K |
| D1351 |
Sealant - per tooth |
816 |
178 |
$18K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,733 |
694 |
$17K |
| D0145 |
Oral evaluation for a patient under three years of age |
109 |
104 |
$13K |
| D1206 |
Topical application of fluoride varnish |
927 |
892 |
$12K |
| D1110 |
Prophylaxis - adult |
220 |
218 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
123 |
68 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
842 |
765 |
$8K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
52 |
25 |
$8K |
| D0272 |
Bitewings - two radiographic images |
289 |
273 |
$6K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
257 |
236 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
123 |
123 |
$4K |
| D0274 |
Bitewings - four radiographic images |
84 |
83 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
42 |
24 |
$2K |
| D0330 |
Panoramic radiographic image |
51 |
51 |
$2K |
| D9248 |
|
26 |
26 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$244.14 |
| D1330 |
|
1,023 |
982 |
$188.75 |
| D0350 |
|
12 |
12 |
$36.76 |
| D0603 |
|
965 |
948 |
$0.00 |
| D1310 |
|
81 |
81 |
$0.00 |
| D0602 |
|
26 |
26 |
$0.00 |
| D0601 |
|
30 |
29 |
$0.00 |