| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,746 |
1,744 |
$60K |
| D1206 |
Topical application of fluoride varnish |
1,669 |
1,667 |
$42K |
| D0120 |
Periodic oral evaluation - established patient |
1,380 |
1,378 |
$33K |
| D1351 |
Sealant - per tooth |
938 |
262 |
$32K |
| D0220 |
Intraoral - periapical first radiographic image |
1,668 |
1,664 |
$20K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
339 |
194 |
$18K |
| D1110 |
Prophylaxis - adult |
332 |
332 |
$15K |
| D0272 |
Bitewings - two radiographic images |
846 |
845 |
$11K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
119 |
76 |
$10K |
| D0274 |
Bitewings - four radiographic images |
405 |
405 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
381 |
381 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,007 |
1,006 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
388 |
386 |
$5K |
| D0145 |
Oral evaluation for a patient under three years of age |
189 |
189 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
91 |
70 |
$3K |
| D0330 |
Panoramic radiographic image |
80 |
80 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
43 |
31 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
103 |
103 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
86 |
85 |
$1K |
| 99429 |
|
375 |
371 |
$0.00 |