| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,167 |
2,143 |
$5K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
335 |
116 |
$5K |
| D1206 |
Topical application of fluoride varnish |
2,476 |
2,448 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
2,196 |
2,170 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
222 |
99 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
349 |
194 |
$2K |
| D0272 |
Bitewings - two radiographic images |
1,040 |
1,008 |
$2K |
| D1351 |
Sealant - per tooth |
999 |
249 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
799 |
769 |
$998.35 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
72 |
72 |
$566.86 |
| D0230 |
Intraoral - periapical each additional radiographic image |
312 |
252 |
$366.84 |
| D0140 |
Limited oral evaluation - problem focused |
167 |
155 |
$344.40 |
| D0330 |
Panoramic radiographic image |
29 |
29 |
$324.96 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
414 |
389 |
$298.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
31 |
25 |
$212.34 |
| D1110 |
Prophylaxis - adult |
177 |
175 |
$142.68 |
| D0274 |
Bitewings - four radiographic images |
54 |
50 |
$89.97 |
| D1354 |
|
41 |
13 |
$58.05 |
| D0145 |
Oral evaluation for a patient under three years of age |
15 |
15 |
$29.96 |
| D1330 |
|
2,597 |
2,394 |
$0.00 |
| D0603 |
|
1,562 |
1,308 |
$0.00 |