| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,400 |
3,400 |
$205K |
| D1110 |
Prophylaxis - adult |
1,515 |
1,515 |
$129K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,279 |
806 |
$108K |
| D0330 |
Panoramic radiographic image |
658 |
658 |
$44K |
| D0210 |
Intraoral - complete series of radiographic images |
262 |
262 |
$38K |
| D1351 |
Sealant - per tooth |
5,387 |
799 |
$34K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
385 |
294 |
$28K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
247 |
99 |
$28K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
356 |
356 |
$20K |
| D7140 |
Extraction, erupted tooth or exposed root |
299 |
177 |
$10K |
| D0274 |
Bitewings - four radiographic images |
1,218 |
1,218 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
181 |
179 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
4,464 |
4,464 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
1,426 |
1,245 |
$203.38 |
| D1208 |
Topical application of fluoride, excluding varnish |
4,177 |
4,177 |
$72.91 |
| D0272 |
Bitewings - two radiographic images |
2,149 |
2,149 |
$15.87 |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,218 |
976 |
$0.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,185 |
1,096 |
$-99.44 |