| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
5,374 |
5,182 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,280 |
545 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
5,252 |
5,060 |
$2K |
| D1206 |
Topical application of fluoride varnish |
6,148 |
5,900 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
7,803 |
3,617 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
4,132 |
3,902 |
$570.29 |
| D1110 |
Prophylaxis - adult |
508 |
485 |
$484.00 |
| D0272 |
Bitewings - two radiographic images |
2,631 |
2,506 |
$415.11 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
653 |
612 |
$334.80 |
| D0274 |
Bitewings - four radiographic images |
277 |
258 |
$303.62 |
| D0330 |
Panoramic radiographic image |
268 |
262 |
$0.00 |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
165 |
67 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
105 |
51 |
$0.00 |
| D1999 |
|
273 |
259 |
$0.00 |
| D1330 |
|
4,185 |
3,866 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
682 |
629 |
$0.00 |
| D1351 |
Sealant - per tooth |
533 |
136 |
$0.00 |
| D0140 |
Limited oral evaluation - problem focused |
46 |
45 |
$0.00 |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
33 |
12 |
$0.00 |
| D7140 |
Extraction, erupted tooth or exposed root |
30 |
12 |
$0.00 |
| D0210 |
Intraoral - complete series of radiographic images |
84 |
79 |
$0.00 |