| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
4,411 |
4,377 |
$34K |
| D1208 |
Topical application of fluoride, excluding varnish |
5,368 |
5,325 |
$18K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,805 |
2,345 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
4,074 |
4,051 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,007 |
993 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
3,076 |
3,003 |
$8K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
361 |
120 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
497 |
285 |
$5K |
| D0274 |
Bitewings - four radiographic images |
1,239 |
1,232 |
$4K |
| D0330 |
Panoramic radiographic image |
516 |
508 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
378 |
210 |
$3K |
| D9248 |
|
319 |
309 |
$3K |
| D0272 |
Bitewings - two radiographic images |
1,186 |
1,179 |
$3K |
| D1110 |
Prophylaxis - adult |
603 |
599 |
$2K |
| D1351 |
Sealant - per tooth |
261 |
83 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
254 |
238 |
$1K |
| D1999 |
|
1,831 |
1,703 |
$352.50 |
| D7140 |
Extraction, erupted tooth or exposed root |
16 |
13 |
$344.85 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
72 |
69 |
$154.18 |
| D0603 |
|
238 |
234 |
$0.00 |
| D0602 |
|
86 |
86 |
$0.00 |
| D0601 |
|
12 |
12 |
$0.00 |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$0.00 |