| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
935 |
933 |
$83K |
| D1120 |
Prophylaxis - child |
1,060 |
1,059 |
$80K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,217 |
667 |
$59K |
| D9420 |
|
101 |
101 |
$46K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
277 |
187 |
$39K |
| D0120 |
Periodic oral evaluation - established patient |
1,685 |
1,684 |
$14K |
| D0210 |
Intraoral - complete series of radiographic images |
123 |
123 |
$14K |
| D0330 |
Panoramic radiographic image |
308 |
307 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
539 |
342 |
$10K |
| D7140 |
Extraction, erupted tooth or exposed root |
243 |
116 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
523 |
521 |
$9K |
| D0274 |
Bitewings - four radiographic images |
1,045 |
1,044 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
363 |
361 |
$7K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
197 |
47 |
$7K |
| D0272 |
Bitewings - two radiographic images |
960 |
955 |
$2K |
| D1351 |
Sealant - per tooth |
1,436 |
293 |
$936.69 |
| D0220 |
Intraoral - periapical first radiographic image |
1,536 |
1,491 |
$830.35 |
| D1208 |
Topical application of fluoride, excluding varnish |
2,011 |
2,008 |
$470.12 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
152 |
130 |
$213.17 |
| D0240 |
|
13 |
13 |
$8.70 |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,061 |
1,056 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
108 |
108 |
$0.00 |