| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,722 |
1,579 |
$40K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,021 |
980 |
$32K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
321 |
226 |
$28K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
363 |
247 |
$21K |
| D1206 |
Topical application of fluoride varnish |
935 |
877 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
623 |
569 |
$15K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
644 |
603 |
$14K |
| D1351 |
Sealant - per tooth |
691 |
236 |
$14K |
| D0272 |
Bitewings - two radiographic images |
731 |
642 |
$11K |
| D0330 |
Panoramic radiographic image |
313 |
286 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
526 |
503 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
834 |
733 |
$7K |
| D0274 |
Bitewings - four radiographic images |
228 |
225 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
628 |
536 |
$5K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
34 |
25 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
42 |
42 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
37 |
37 |
$2K |
| D1110 |
Prophylaxis - adult |
17 |
17 |
$831.40 |
| D1999 |
|
175 |
172 |
$0.00 |