| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
4,754 |
4,699 |
$2K |
| D1351 |
Sealant - per tooth |
1,983 |
564 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
4,989 |
4,920 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,480 |
687 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
5,700 |
5,618 |
$932.96 |
| D1110 |
Prophylaxis - adult |
1,048 |
1,020 |
$678.86 |
| D0274 |
Bitewings - four radiographic images |
2,246 |
2,211 |
$635.00 |
| D0220 |
Intraoral - periapical first radiographic image |
5,622 |
5,398 |
$598.54 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
884 |
443 |
$581.85 |
| D0330 |
Panoramic radiographic image |
266 |
266 |
$360.16 |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,144 |
5,082 |
$322.35 |
| D0272 |
Bitewings - two radiographic images |
1,861 |
1,837 |
$274.72 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,300 |
1,212 |
$234.36 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
715 |
703 |
$189.60 |
| D0210 |
Intraoral - complete series of radiographic images |
374 |
364 |
$155.52 |
| D9248 |
|
131 |
117 |
$0.00 |
| D7140 |
Extraction, erupted tooth or exposed root |
88 |
36 |
$0.00 |
| D3120 |
|
440 |
153 |
$0.00 |
| D0140 |
Limited oral evaluation - problem focused |
63 |
57 |
$0.00 |
| D1354 |
|
251 |
76 |
$0.00 |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
316 |
102 |
$0.00 |