| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
784 |
752 |
$38K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
188 |
73 |
$30K |
| D0210 |
Intraoral - complete series of radiographic images |
203 |
190 |
$29K |
| D1110 |
Prophylaxis - adult |
285 |
273 |
$25K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
110 |
71 |
$13K |
| D9248 |
|
135 |
127 |
$6K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
139 |
132 |
$6K |
| D1351 |
Sealant - per tooth |
797 |
174 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
84 |
49 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
32 |
28 |
$1K |
| D1120 |
Prophylaxis - child |
567 |
542 |
$358.50 |
| D0240 |
|
658 |
341 |
$85.62 |
| D0220 |
Intraoral - periapical first radiographic image |
99 |
95 |
$37.47 |
| D0272 |
Bitewings - two radiographic images |
489 |
472 |
$16.06 |
| D0274 |
Bitewings - four radiographic images |
104 |
98 |
$0.00 |
| D7140 |
Extraction, erupted tooth or exposed root |
170 |
88 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
801 |
768 |
$0.00 |
| D1330 |
|
837 |
801 |
$0.00 |
| D3120 |
|
14 |
12 |
$0.00 |