| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
10,201 |
9,848 |
$233K |
| D1120 |
Prophylaxis - child |
8,778 |
8,750 |
$227K |
| D0120 |
Periodic oral evaluation - established patient |
9,169 |
9,133 |
$203K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,265 |
588 |
$142K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,241 |
561 |
$90K |
| D0272 |
Bitewings - two radiographic images |
6,270 |
6,251 |
$71K |
| D1351 |
Sealant - per tooth |
2,889 |
625 |
$70K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,914 |
1,842 |
$55K |
| D0274 |
Bitewings - four radiographic images |
2,246 |
2,236 |
$39K |
| D0210 |
Intraoral - complete series of radiographic images |
814 |
814 |
$38K |
| D1110 |
Prophylaxis - adult |
850 |
844 |
$28K |
| D0140 |
Limited oral evaluation - problem focused |
430 |
417 |
$9K |
| D0145 |
Oral evaluation for a patient under three years of age |
207 |
207 |
$8K |
| D1999 |
|
727 |
677 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
55 |
33 |
$3K |
| D0330 |
Panoramic radiographic image |
1,013 |
1,013 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
200 |
191 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
26 |
26 |
$750.13 |
| D0230 |
Intraoral - periapical each additional radiographic image |
55 |
54 |
$255.00 |