| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,701 |
1,701 |
$109K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
673 |
256 |
$66K |
| D1110 |
Prophylaxis - adult |
544 |
544 |
$52K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
493 |
330 |
$24K |
| D7140 |
Extraction, erupted tooth or exposed root |
519 |
278 |
$23K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
294 |
294 |
$22K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
279 |
218 |
$21K |
| D0210 |
Intraoral - complete series of radiographic images |
138 |
138 |
$18K |
| D0330 |
Panoramic radiographic image |
332 |
332 |
$18K |
| D1351 |
Sealant - per tooth |
2,263 |
611 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
225 |
223 |
$6K |
| D0274 |
Bitewings - four radiographic images |
555 |
555 |
$404.57 |
| D9420 |
|
48 |
48 |
$367.71 |
| D2330 |
|
18 |
12 |
$289.74 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
842 |
783 |
$134.20 |
| D0272 |
Bitewings - two radiographic images |
1,437 |
1,437 |
$114.68 |
| D0120 |
Periodic oral evaluation - established patient |
1,967 |
1,967 |
$87.63 |
| D0220 |
Intraoral - periapical first radiographic image |
1,149 |
1,125 |
$27.66 |
| D1208 |
Topical application of fluoride, excluding varnish |
2,151 |
2,151 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
808 |
657 |
$0.00 |