| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
5,388 |
5,332 |
$22K |
| D1206 |
Topical application of fluoride varnish |
5,780 |
5,722 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
923 |
399 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
4,264 |
4,214 |
$8K |
| D0272 |
Bitewings - two radiographic images |
4,210 |
4,146 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,407 |
1,380 |
$7K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,479 |
1,406 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
3,655 |
3,581 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,092 |
2,968 |
$2K |
| D1351 |
Sealant - per tooth |
1,119 |
334 |
$2K |
| D0330 |
Panoramic radiographic image |
601 |
594 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
162 |
87 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
120 |
120 |
$2K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
127 |
67 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
259 |
140 |
$1K |
| D0274 |
Bitewings - four radiographic images |
436 |
429 |
$649.76 |
| D0140 |
Limited oral evaluation - problem focused |
208 |
196 |
$490.42 |
| D1110 |
Prophylaxis - adult |
211 |
208 |
$333.29 |
| D0601 |
|
31 |
31 |
$0.00 |
| D0603 |
|
1,221 |
1,133 |
$0.00 |
| D0602 |
|
131 |
125 |
$0.00 |
| D1354 |
|
76 |
14 |
$0.00 |