| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
4,426 |
4,420 |
$282K |
| D1110 |
Prophylaxis - adult |
2,089 |
2,089 |
$183K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,440 |
980 |
$135K |
| D0330 |
Panoramic radiographic image |
951 |
951 |
$84K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
400 |
198 |
$59K |
| D1351 |
Sealant - per tooth |
6,973 |
1,169 |
$22K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
276 |
224 |
$18K |
| D0274 |
Bitewings - four radiographic images |
1,730 |
1,730 |
$17K |
| D0210 |
Intraoral - complete series of radiographic images |
95 |
95 |
$16K |
| D7140 |
Extraction, erupted tooth or exposed root |
64 |
39 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,638 |
1,638 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
4,994 |
4,988 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,332 |
2,133 |
$1K |
| D8660 |
|
12 |
12 |
$900.00 |
| D0140 |
Limited oral evaluation - problem focused |
27 |
26 |
$600.38 |
| D0220 |
Intraoral - periapical first radiographic image |
232 |
227 |
$59.39 |
| D1206 |
Topical application of fluoride varnish |
5,962 |
5,956 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
272 |
272 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
3,767 |
3,762 |
$-13.06 |