| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,212 |
1,970 |
$109K |
| D1206 |
Topical application of fluoride varnish |
943 |
854 |
$44K |
| D0140 |
Limited oral evaluation - problem focused |
1,406 |
1,195 |
$40K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
645 |
317 |
$30K |
| D1351 |
Sealant - per tooth |
651 |
174 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
426 |
376 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
313 |
179 |
$12K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,213 |
1,058 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
284 |
272 |
$8K |
| D0272 |
Bitewings - two radiographic images |
421 |
370 |
$8K |
| D0274 |
Bitewings - four radiographic images |
207 |
193 |
$4K |
| D0330 |
Panoramic radiographic image |
76 |
72 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
158 |
138 |
$2K |
| D7111 |
|
47 |
31 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
148 |
120 |
$2K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
19 |
12 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$707.28 |
| D0230 |
Intraoral - periapical each additional radiographic image |
62 |
17 |
$212.04 |
| D0191 |
|
16 |
15 |
$163.23 |