| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,690 |
3,620 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,701 |
1,667 |
$3K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
657 |
255 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,982 |
3,912 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,027 |
443 |
$1K |
| D1351 |
Sealant - per tooth |
1,328 |
341 |
$1K |
| D0272 |
Bitewings - two radiographic images |
1,685 |
1,649 |
$777.91 |
| D1110 |
Prophylaxis - adult |
580 |
570 |
$522.56 |
| D0330 |
Panoramic radiographic image |
449 |
438 |
$417.06 |
| D9248 |
|
30 |
26 |
$336.03 |
| D0145 |
Oral evaluation for a patient under three years of age |
481 |
475 |
$287.64 |
| D0274 |
Bitewings - four radiographic images |
392 |
389 |
$260.92 |
| D0120 |
Periodic oral evaluation - established patient |
2,023 |
1,990 |
$234.64 |
| D0220 |
Intraoral - periapical first radiographic image |
828 |
777 |
$152.90 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
470 |
457 |
$136.15 |
| D7140 |
Extraction, erupted tooth or exposed root |
100 |
51 |
$84.29 |
| D0140 |
Limited oral evaluation - problem focused |
142 |
137 |
$75.76 |
| D0230 |
Intraoral - periapical each additional radiographic image |
772 |
367 |
$46.01 |
| D1206 |
Topical application of fluoride varnish |
14 |
14 |
$0.00 |
| D1354 |
|
341 |
137 |
$0.00 |