| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
10,807 |
10,807 |
$509K |
| D0120 |
Periodic oral evaluation - established patient |
10,113 |
10,113 |
$322K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,386 |
1,663 |
$280K |
| D1206 |
Topical application of fluoride varnish |
4,751 |
4,751 |
$157K |
| D0272 |
Bitewings - two radiographic images |
5,492 |
5,490 |
$103K |
| D1208 |
Topical application of fluoride, excluding varnish |
6,590 |
6,590 |
$101K |
| D1110 |
Prophylaxis - adult |
934 |
934 |
$60K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,501 |
1,501 |
$50K |
| D1351 |
Sealant - per tooth |
926 |
312 |
$48K |
| D0240 |
|
960 |
960 |
$32K |
| D0220 |
Intraoral - periapical first radiographic image |
1,238 |
1,237 |
$19K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,018 |
966 |
$15K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
105 |
83 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
81 |
60 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
294 |
294 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
142 |
142 |
$2K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
12 |
12 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
26 |
26 |
$861.90 |
| D0330 |
Panoramic radiographic image |
14 |
14 |
$574.60 |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$95.94 |
| D1999 |
|
393 |
380 |
$0.00 |