| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,838 |
3,717 |
$233K |
| D1351 |
Sealant - per tooth |
3,443 |
599 |
$153K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
855 |
435 |
$139K |
| D0120 |
Periodic oral evaluation - established patient |
2,097 |
2,074 |
$99K |
| D1206 |
Topical application of fluoride varnish |
3,264 |
3,157 |
$88K |
| D0272 |
Bitewings - two radiographic images |
1,548 |
1,492 |
$59K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
912 |
870 |
$56K |
| D0330 |
Panoramic radiographic image |
447 |
424 |
$41K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
274 |
169 |
$36K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
832 |
571 |
$32K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
316 |
65 |
$32K |
| D0145 |
Oral evaluation for a patient under three years of age |
545 |
539 |
$29K |
| D0140 |
Limited oral evaluation - problem focused |
403 |
377 |
$25K |
| D0240 |
|
780 |
402 |
$22K |
| D0230 |
Intraoral - periapical each additional radiographic image |
104 |
24 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
13 |
13 |
$268.73 |
| D0602 |
|
991 |
981 |
$0.00 |
| D1330 |
|
1,258 |
1,225 |
$0.00 |
| D0603 |
|
2,078 |
2,010 |
$0.00 |
| D0601 |
|
16 |
16 |
$0.00 |
| D1999 |
|
39 |
28 |
$0.00 |