| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,858 |
1,838 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
564 |
254 |
$7K |
| D1206 |
Topical application of fluoride varnish |
2,135 |
2,117 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,780 |
1,391 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
679 |
674 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
1,387 |
1,377 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
1,637 |
1,610 |
$2K |
| D0330 |
Panoramic radiographic image |
292 |
291 |
$2K |
| D0274 |
Bitewings - four radiographic images |
494 |
489 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
429 |
376 |
$997.57 |
| D1110 |
Prophylaxis - adult |
82 |
80 |
$733.84 |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
24 |
13 |
$731.64 |
| D0272 |
Bitewings - two radiographic images |
235 |
234 |
$583.02 |
| D1351 |
Sealant - per tooth |
179 |
73 |
$437.82 |
| D0140 |
Limited oral evaluation - problem focused |
14 |
13 |
$103.32 |
| D0350 |
|
46 |
12 |
$0.00 |
| D1330 |
|
139 |
132 |
$0.00 |