| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
4,056 |
3,869 |
$12K |
| D1206 |
Topical application of fluoride varnish |
4,398 |
4,204 |
$6K |
| D0272 |
Bitewings - two radiographic images |
2,909 |
2,795 |
$4K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
331 |
105 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
3,350 |
3,237 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
4,144 |
3,937 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,319 |
3,746 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
393 |
347 |
$2K |
| D0330 |
Panoramic radiographic image |
743 |
719 |
$2K |
| D1351 |
Sealant - per tooth |
762 |
194 |
$2K |
| D1354 |
|
1,635 |
350 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
766 |
662 |
$985.75 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
521 |
198 |
$752.94 |
| D0145 |
Oral evaluation for a patient under three years of age |
205 |
198 |
$539.90 |
| D0274 |
Bitewings - four radiographic images |
291 |
269 |
$321.49 |
| D1110 |
Prophylaxis - adult |
139 |
137 |
$197.12 |
| D7140 |
Extraction, erupted tooth or exposed root |
118 |
55 |
$133.40 |
| D9248 |
|
29 |
25 |
$70.18 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
12 |
$34.44 |
| D0601 |
|
14 |
14 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
21 |
13 |
$0.00 |