| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
798 |
798 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
924 |
924 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
773 |
773 |
$4K |
| D0272 |
Bitewings - two radiographic images |
546 |
546 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
401 |
398 |
$2K |
| D1206 |
Topical application of fluoride varnish |
56 |
56 |
$2K |
| D0330 |
Panoramic radiographic image |
196 |
196 |
$2K |
| D1351 |
Sealant - per tooth |
177 |
56 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
80 |
64 |
$1K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
27 |
13 |
$1K |
| D0274 |
Bitewings - four radiographic images |
171 |
171 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
58 |
51 |
$993.27 |
| D1354 |
|
48 |
14 |
$634.25 |
| D7140 |
Extraction, erupted tooth or exposed root |
23 |
16 |
$413.25 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
25 |
25 |
$381.93 |
| D1110 |
Prophylaxis - adult |
27 |
27 |
$353.16 |
| D0140 |
Limited oral evaluation - problem focused |
57 |
57 |
$279.63 |
| D0240 |
|
17 |
15 |
$133.25 |
| D0270 |
|
13 |
13 |
$41.30 |
| D1330 |
|
666 |
666 |
$0.00 |
| D9630 |
|
24 |
24 |
$0.00 |
| D9215 |
|
47 |
47 |
$0.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
142 |
140 |
$0.00 |