| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,874 |
3,868 |
$258K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,065 |
257 |
$91K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
942 |
938 |
$75K |
| D1110 |
Prophylaxis - adult |
685 |
684 |
$72K |
| D0330 |
Panoramic radiographic image |
223 |
223 |
$21K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
253 |
150 |
$21K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
233 |
156 |
$11K |
| D1351 |
Sealant - per tooth |
3,047 |
652 |
$11K |
| D0145 |
Oral evaluation for a patient under three years of age |
380 |
380 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
93 |
50 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
113 |
113 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
3,261 |
3,258 |
$1K |
| D1354 |
|
741 |
274 |
$1K |
| D0274 |
Bitewings - four radiographic images |
644 |
643 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
7,473 |
3,938 |
$120.79 |
| D0220 |
Intraoral - periapical first radiographic image |
4,209 |
4,166 |
$75.06 |
| D0272 |
Bitewings - two radiographic images |
2,077 |
2,073 |
$74.30 |
| D1206 |
Topical application of fluoride varnish |
1,051 |
1,049 |
$13.55 |
| D1208 |
Topical application of fluoride, excluding varnish |
3,464 |
3,460 |
$0.00 |
| D9420 |
|
129 |
129 |
$0.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,100 |
1,039 |
$0.00 |