| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,898 |
2,697 |
$102.00 |
| D0210 |
Intraoral - complete series of radiographic images |
293 |
293 |
$94.63 |
| D1351 |
Sealant - per tooth |
1,285 |
461 |
$84.00 |
| D0120 |
Periodic oral evaluation - established patient |
3,033 |
2,807 |
$44.00 |
| D0220 |
Intraoral - periapical first radiographic image |
1,673 |
1,488 |
$30.28 |
| D1208 |
Topical application of fluoride, excluding varnish |
1,761 |
1,614 |
$30.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
431 |
360 |
$29.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
697 |
639 |
$28.00 |
| D0140 |
Limited oral evaluation - problem focused |
125 |
107 |
$22.62 |
| D1206 |
Topical application of fluoride varnish |
1,935 |
1,807 |
$15.00 |
| D0272 |
Bitewings - two radiographic images |
1,682 |
1,562 |
$14.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,504 |
1,056 |
$5.00 |
| D0274 |
Bitewings - four radiographic images |
999 |
911 |
$0.00 |
| D0330 |
Panoramic radiographic image |
619 |
533 |
$0.00 |
| D1110 |
Prophylaxis - adult |
797 |
723 |
$0.00 |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
22 |
13 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
179 |
131 |
$0.00 |
| D0350 |
|
212 |
50 |
$0.00 |
| D1354 |
|
144 |
29 |
$0.00 |
| D1330 |
|
1,106 |
1,023 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
392 |
259 |
$0.00 |
| D9999 |
Unspecified adjunctive procedure, by report |
17 |
17 |
$0.00 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
39 |
26 |
$0.00 |