| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,177 |
3,177 |
$195K |
| D1110 |
Prophylaxis - adult |
1,651 |
1,650 |
$129K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,032 |
1,231 |
$120K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
433 |
433 |
$22K |
| D0330 |
Panoramic radiographic image |
292 |
292 |
$19K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
388 |
291 |
$17K |
| D0210 |
Intraoral - complete series of radiographic images |
138 |
138 |
$11K |
| D9420 |
|
14 |
14 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
278 |
148 |
$5K |
| D1351 |
Sealant - per tooth |
1,982 |
346 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
4,435 |
4,433 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
19 |
16 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
55 |
55 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
519 |
464 |
$656.62 |
| D0220 |
Intraoral - periapical first radiographic image |
1,677 |
1,607 |
$386.16 |
| D0274 |
Bitewings - four radiographic images |
1,203 |
1,203 |
$97.84 |
| D0272 |
Bitewings - two radiographic images |
2,021 |
2,020 |
$25.60 |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,076 |
1,233 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
4,295 |
4,294 |
$-74.47 |