| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
563 |
536 |
$28K |
| D0210 |
Intraoral - complete series of radiographic images |
179 |
171 |
$24K |
| D1110 |
Prophylaxis - adult |
176 |
170 |
$16K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
80 |
56 |
$16K |
| D9248 |
|
111 |
105 |
$6K |
| D1351 |
Sealant - per tooth |
367 |
80 |
$3K |
| D1120 |
Prophylaxis - child |
426 |
404 |
$979.40 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
16 |
16 |
$369.23 |
| D7140 |
Extraction, erupted tooth or exposed root |
92 |
44 |
$76.16 |
| D0272 |
Bitewings - two radiographic images |
335 |
318 |
$44.60 |
| D0240 |
|
463 |
243 |
$14.27 |
| D0220 |
Intraoral - periapical first radiographic image |
69 |
67 |
$7.14 |
| D1330 |
|
591 |
563 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
549 |
523 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
46 |
45 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
50 |
49 |
$0.00 |