| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,678 |
3,652 |
$102K |
| D1206 |
Topical application of fluoride varnish |
4,436 |
4,405 |
$77K |
| D0120 |
Periodic oral evaluation - established patient |
3,459 |
3,447 |
$57K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
678 |
376 |
$40K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
844 |
752 |
$21K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
680 |
664 |
$18K |
| D1110 |
Prophylaxis - adult |
437 |
437 |
$17K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,452 |
817 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
1,250 |
1,233 |
$9K |
| D0272 |
Bitewings - two radiographic images |
474 |
474 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
175 |
92 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
253 |
231 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
126 |
81 |
$5K |
| D1351 |
Sealant - per tooth |
185 |
58 |
$2K |
| D9920 |
|
12 |
12 |
$822.00 |
| D0274 |
Bitewings - four radiographic images |
40 |
40 |
$745.20 |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
52 |
14 |
$0.00 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$0.00 |