| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,637 |
1,637 |
$72K |
| D1206 |
Topical application of fluoride varnish |
1,662 |
1,662 |
$48K |
| D1351 |
Sealant - per tooth |
2,136 |
416 |
$47K |
| D0120 |
Periodic oral evaluation - established patient |
1,241 |
1,239 |
$32K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
244 |
120 |
$20K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
106 |
41 |
$14K |
| D0272 |
Bitewings - two radiographic images |
788 |
783 |
$12K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
326 |
272 |
$8K |
| D0603 |
|
949 |
941 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
697 |
689 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
468 |
465 |
$4K |
| D0330 |
Panoramic radiographic image |
74 |
74 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
64 |
64 |
$3K |
| D0601 |
|
301 |
299 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
29 |
28 |
$793.00 |
| D0145 |
Oral evaluation for a patient under three years of age |
17 |
17 |
$645.00 |
| D0274 |
Bitewings - four radiographic images |
17 |
17 |
$416.00 |
| D0240 |
|
18 |
13 |
$265.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
14 |
14 |
$225.00 |
| D1330 |
|
158 |
155 |
$0.00 |
| D1310 |
|
105 |
104 |
$0.00 |