| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,154 |
3,034 |
$866.44 |
| D0120 |
Periodic oral evaluation - established patient |
2,927 |
2,823 |
$513.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
3,236 |
3,154 |
$437.25 |
| D0220 |
Intraoral - periapical first radiographic image |
3,967 |
3,749 |
$311.50 |
| D0330 |
Panoramic radiographic image |
393 |
381 |
$227.35 |
| D0274 |
Bitewings - four radiographic images |
1,344 |
1,285 |
$223.55 |
| D1110 |
Prophylaxis - adult |
273 |
261 |
$195.88 |
| D0272 |
Bitewings - two radiographic images |
1,720 |
1,646 |
$195.84 |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,004 |
3,371 |
$144.09 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
655 |
368 |
$128.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
698 |
669 |
$60.64 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
316 |
189 |
$56.00 |
| D1206 |
Topical application of fluoride varnish |
545 |
486 |
$30.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
572 |
497 |
$0.00 |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
19 |
14 |
$0.00 |
| D0603 |
|
108 |
99 |
$0.00 |
| D0602 |
|
259 |
247 |
$0.00 |
| D1351 |
Sealant - per tooth |
108 |
40 |
$0.00 |
| D0210 |
Intraoral - complete series of radiographic images |
64 |
63 |
$0.00 |
| D0140 |
Limited oral evaluation - problem focused |
224 |
185 |
$0.00 |