| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,051 |
1,977 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
1,977 |
1,926 |
$846.12 |
| D1208 |
Topical application of fluoride, excluding varnish |
2,367 |
2,295 |
$542.70 |
| D0220 |
Intraoral - periapical first radiographic image |
2,519 |
2,420 |
$410.82 |
| D0274 |
Bitewings - four radiographic images |
980 |
950 |
$333.45 |
| D0272 |
Bitewings - two radiographic images |
1,232 |
1,193 |
$282.03 |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,399 |
2,308 |
$203.09 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
283 |
267 |
$130.56 |
| D1110 |
Prophylaxis - adult |
153 |
149 |
$48.97 |
| D0603 |
|
272 |
265 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
231 |
116 |
$0.00 |
| D1351 |
Sealant - per tooth |
375 |
109 |
$0.00 |
| D0210 |
Intraoral - complete series of radiographic images |
120 |
120 |
$0.00 |
| D9248 |
|
12 |
12 |
$0.00 |
| D0140 |
Limited oral evaluation - problem focused |
34 |
29 |
$0.00 |
| D7140 |
Extraction, erupted tooth or exposed root |
68 |
29 |
$0.00 |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
48 |
15 |
$0.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
190 |
160 |
$0.00 |
| D0330 |
Panoramic radiographic image |
167 |
147 |
$0.00 |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
348 |
62 |
$0.00 |