| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,046 |
1,038 |
$45K |
| D1206 |
Topical application of fluoride varnish |
1,078 |
1,069 |
$33K |
| D0120 |
Periodic oral evaluation - established patient |
937 |
931 |
$23K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
297 |
155 |
$21K |
| D1351 |
Sealant - per tooth |
778 |
178 |
$14K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
133 |
88 |
$7K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
266 |
254 |
$6K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
57 |
39 |
$6K |
| D0272 |
Bitewings - two radiographic images |
547 |
547 |
$5K |
| D0603 |
|
425 |
422 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
644 |
634 |
$3K |
| D0240 |
|
128 |
128 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
553 |
544 |
$2K |
| D1353 |
|
153 |
30 |
$1K |
| D0601 |
|
85 |
83 |
$770.00 |
| D0274 |
Bitewings - four radiographic images |
64 |
64 |
$732.00 |
| D0140 |
Limited oral evaluation - problem focused |
15 |
14 |
$625.00 |
| D1110 |
Prophylaxis - adult |
13 |
13 |
$360.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
13 |
13 |
$325.00 |
| D9920 |
|
13 |
13 |
$260.00 |
| D0602 |
|
13 |
13 |
$120.00 |
| D1320 |
|
56 |
56 |
$0.00 |
| D1330 |
|
56 |
56 |
$0.00 |
| D1310 |
|
55 |
55 |
$0.00 |