| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,795 |
1,792 |
$86K |
| D1351 |
Sealant - per tooth |
1,973 |
388 |
$77K |
| D1206 |
Topical application of fluoride varnish |
1,930 |
1,927 |
$50K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
363 |
177 |
$50K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
769 |
766 |
$43K |
| D0120 |
Periodic oral evaluation - established patient |
974 |
974 |
$31K |
| D0330 |
Panoramic radiographic image |
314 |
314 |
$14K |
| D0145 |
Oral evaluation for a patient under three years of age |
223 |
223 |
$10K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
486 |
432 |
$10K |
| D0272 |
Bitewings - two radiographic images |
578 |
576 |
$9K |
| D1110 |
Prophylaxis - adult |
117 |
117 |
$8K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
36 |
12 |
$6K |
| D1330 |
|
652 |
651 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
87 |
86 |
$4K |
| D0274 |
Bitewings - four radiographic images |
92 |
92 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
15 |
15 |
$363.90 |
| D0220 |
Intraoral - periapical first radiographic image |
14 |
14 |
$165.48 |