| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,604 |
1,603 |
$49K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
467 |
288 |
$46K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
754 |
465 |
$44K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
813 |
799 |
$36K |
| D1206 |
Topical application of fluoride varnish |
1,739 |
1,736 |
$32K |
| D0120 |
Periodic oral evaluation - established patient |
1,292 |
1,291 |
$26K |
| D8670 |
Periodic orthodontic treatment visit |
226 |
226 |
$18K |
| D0272 |
Bitewings - two radiographic images |
1,025 |
1,025 |
$17K |
| D0330 |
Panoramic radiographic image |
322 |
322 |
$12K |
| D7140 |
Extraction, erupted tooth or exposed root |
181 |
126 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
466 |
466 |
$10K |
| D1330 |
|
1,306 |
1,305 |
$7K |
| D1110 |
Prophylaxis - adult |
128 |
128 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
88 |
75 |
$4K |
| D1351 |
Sealant - per tooth |
145 |
64 |
$4K |
| D1310 |
|
239 |
238 |
$2K |
| D0601 |
|
184 |
184 |
$2K |
| D0603 |
|
177 |
176 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
70 |
70 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
114 |
114 |
$1K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
16 |
16 |
$1K |
| D0274 |
Bitewings - four radiographic images |
20 |
20 |
$569.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
57 |
49 |
$557.68 |
| D1354 |
|
25 |
24 |
$365.00 |
| D1999 |
|
282 |
274 |
$0.00 |