| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,626 |
2,574 |
$6K |
| D1206 |
Topical application of fluoride varnish |
2,134 |
2,114 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
66 |
24 |
$2K |
| D0272 |
Bitewings - two radiographic images |
1,011 |
976 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
2,413 |
2,367 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
200 |
191 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
2,129 |
2,054 |
$1K |
| D1351 |
Sealant - per tooth |
776 |
239 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
96 |
55 |
$598.43 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
310 |
286 |
$495.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,179 |
1,640 |
$461.16 |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
22 |
13 |
$365.82 |
| D0140 |
Limited oral evaluation - problem focused |
34 |
30 |
$137.76 |
| D1110 |
Prophylaxis - adult |
77 |
76 |
$95.12 |
| D1208 |
Topical application of fluoride, excluding varnish |
518 |
488 |
$86.60 |
| D1354 |
|
314 |
92 |
$77.40 |
| D0330 |
Panoramic radiographic image |
25 |
25 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
154 |
154 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
43 |
25 |
$0.00 |
| D0210 |
Intraoral - complete series of radiographic images |
56 |
55 |
$0.00 |
| D1330 |
|
2,148 |
1,999 |
$0.00 |
| D0603 |
|
964 |
827 |
$0.00 |