| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
1,155 |
948 |
$34K |
| D1120 |
Prophylaxis - child |
918 |
769 |
$33K |
| T1015 |
Clinic visit/encounter, all-inclusive |
265 |
263 |
$25K |
| D0120 |
Periodic oral evaluation - established patient |
744 |
609 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
179 |
113 |
$12K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
87 |
65 |
$9K |
| D1351 |
Sealant - per tooth |
379 |
139 |
$6K |
| D0330 |
Panoramic radiographic image |
134 |
123 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
245 |
202 |
$6K |
| D0272 |
Bitewings - two radiographic images |
310 |
248 |
$5K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
114 |
111 |
$3K |
| D0274 |
Bitewings - four radiographic images |
122 |
108 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
40 |
25 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
66 |
59 |
$1K |
| D1354 |
|
87 |
16 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
24 |
17 |
$1K |
| D1110 |
Prophylaxis - adult |
14 |
14 |
$560.00 |
| D0220 |
Intraoral - periapical first radiographic image |
38 |
38 |
$458.00 |