| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,276 |
1,253 |
$4K |
| D1206 |
Topical application of fluoride varnish |
1,496 |
1,466 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
1,296 |
1,275 |
$1K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
43 |
17 |
$1K |
| D1351 |
Sealant - per tooth |
492 |
138 |
$987.24 |
| D0272 |
Bitewings - two radiographic images |
587 |
572 |
$924.40 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
27 |
27 |
$728.82 |
| D7140 |
Extraction, erupted tooth or exposed root |
57 |
27 |
$689.67 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
37 |
23 |
$637.02 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
63 |
38 |
$427.45 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
154 |
147 |
$222.75 |
| D0145 |
Oral evaluation for a patient under three years of age |
28 |
27 |
$209.72 |
| D0220 |
Intraoral - periapical first radiographic image |
193 |
182 |
$156.24 |
| D1354 |
|
58 |
16 |
$116.10 |
| D0230 |
Intraoral - periapical each additional radiographic image |
44 |
42 |
$64.20 |
| D1110 |
Prophylaxis - adult |
94 |
92 |
$47.56 |
| D0274 |
Bitewings - four radiographic images |
13 |
12 |
$29.99 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$0.00 |
| D1330 |
|
1,368 |
1,283 |
$0.00 |
| D0603 |
|
751 |
645 |
$0.00 |
| D0140 |
Limited oral evaluation - problem focused |
52 |
51 |
$0.00 |
| D0210 |
Intraoral - complete series of radiographic images |
20 |
18 |
$0.00 |