| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,185 |
3,158 |
$67K |
| D1206 |
Topical application of fluoride varnish |
3,654 |
3,624 |
$49K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
946 |
938 |
$22K |
| D0120 |
Periodic oral evaluation - established patient |
1,839 |
1,823 |
$21K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
681 |
653 |
$13K |
| D0272 |
Bitewings - two radiographic images |
526 |
523 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
115 |
67 |
$6K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
155 |
43 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
102 |
87 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
217 |
217 |
$2K |
| D1351 |
Sealant - per tooth |
133 |
40 |
$1K |
| D1110 |
Prophylaxis - adult |
89 |
86 |
$1K |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$842.28 |
| D0220 |
Intraoral - periapical first radiographic image |
120 |
118 |
$581.20 |
| D0140 |
Limited oral evaluation - problem focused |
58 |
58 |
$451.92 |
| D0274 |
Bitewings - four radiographic images |
119 |
118 |
$430.56 |
| D0240 |
|
33 |
24 |
$143.55 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
23 |
12 |
$0.00 |
| D7140 |
Extraction, erupted tooth or exposed root |
28 |
12 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
24 |
12 |
$0.00 |