| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,855 |
3,831 |
$95K |
| D1206 |
Topical application of fluoride varnish |
4,641 |
4,618 |
$72K |
| D0120 |
Periodic oral evaluation - established patient |
3,522 |
3,500 |
$51K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
718 |
419 |
$46K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
246 |
136 |
$25K |
| D0272 |
Bitewings - two radiographic images |
1,453 |
1,440 |
$21K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
735 |
727 |
$19K |
| D1351 |
Sealant - per tooth |
917 |
314 |
$18K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
577 |
530 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
1,117 |
1,101 |
$10K |
| D9920 |
|
57 |
56 |
$5K |
| D1354 |
|
520 |
201 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
48 |
27 |
$4K |
| D1110 |
Prophylaxis - adult |
169 |
166 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
119 |
117 |
$2K |
| D0330 |
Panoramic radiographic image |
54 |
54 |
$842.28 |
| D0230 |
Intraoral - periapical each additional radiographic image |
17 |
12 |
$0.00 |