| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
6,290 |
6,020 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
6,408 |
6,157 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
7,934 |
7,588 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,102 |
1,359 |
$1K |
| D1110 |
Prophylaxis - adult |
1,633 |
1,573 |
$629.64 |
| D0274 |
Bitewings - four radiographic images |
2,453 |
2,341 |
$491.40 |
| D0330 |
Panoramic radiographic image |
1,011 |
955 |
$461.70 |
| D0230 |
Intraoral - periapical each additional radiographic image |
8,795 |
3,441 |
$454.74 |
| D0220 |
Intraoral - periapical first radiographic image |
4,364 |
4,154 |
$420.80 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,778 |
887 |
$335.36 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,754 |
1,619 |
$222.24 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,317 |
1,228 |
$191.20 |
| D0272 |
Bitewings - two radiographic images |
2,469 |
2,322 |
$178.38 |
| D0140 |
Limited oral evaluation - problem focused |
841 |
733 |
$130.56 |
| D9248 |
|
854 |
764 |
$116.64 |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
541 |
248 |
$95.00 |
| D1351 |
Sealant - per tooth |
1,323 |
374 |
$88.00 |
| D2330 |
|
17 |
13 |
$57.00 |
| D7140 |
Extraction, erupted tooth or exposed root |
516 |
312 |
$56.00 |
| D0210 |
Intraoral - complete series of radiographic images |
378 |
307 |
$0.00 |
| D1999 |
|
1,571 |
1,379 |
$0.00 |
| D0340 |
|
27 |
27 |
$0.00 |