| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,661 |
2,660 |
$93K |
| D1206 |
Topical application of fluoride varnish |
2,676 |
2,675 |
$60K |
| D0120 |
Periodic oral evaluation - established patient |
2,198 |
2,198 |
$52K |
| D1351 |
Sealant - per tooth |
1,229 |
236 |
$22K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
248 |
158 |
$13K |
| D0272 |
Bitewings - two radiographic images |
1,126 |
1,126 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
374 |
374 |
$9K |
| D0602 |
|
701 |
701 |
$7K |
| D0603 |
|
397 |
397 |
$4K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
184 |
176 |
$4K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
35 |
12 |
$3K |
| D0330 |
Panoramic radiographic image |
71 |
71 |
$2K |
| D0240 |
|
65 |
65 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
17 |
17 |
$80.20 |
| D0230 |
Intraoral - periapical each additional radiographic image |
16 |
16 |
$61.95 |
| D1999 |
|
18 |
15 |
$0.00 |