| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,950 |
1,940 |
$69K |
| D0120 |
Periodic oral evaluation - established patient |
1,296 |
1,292 |
$32K |
| D1206 |
Topical application of fluoride varnish |
1,361 |
1,355 |
$24K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
448 |
444 |
$16K |
| D0272 |
Bitewings - two radiographic images |
636 |
633 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
535 |
535 |
$9K |
| D0603 |
|
710 |
701 |
$5K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
192 |
188 |
$5K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
25 |
12 |
$3K |
| D0240 |
|
184 |
97 |
$3K |
| D0602 |
|
234 |
232 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
22 |
12 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
24 |
12 |
$1K |
| D0601 |
|
127 |
127 |
$1K |
| D0145 |
Oral evaluation for a patient under three years of age |
42 |
42 |
$1K |
| D1999 |
|
436 |
419 |
$651.81 |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$638.00 |
| D1320 |
|
49 |
48 |
$490.00 |
| D0140 |
Limited oral evaluation - problem focused |
16 |
15 |
$455.00 |
| D0220 |
Intraoral - periapical first radiographic image |
42 |
39 |
$410.76 |
| D0274 |
Bitewings - four radiographic images |
16 |
16 |
$232.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
35 |
12 |
$207.00 |
| D1330 |
|
1,250 |
1,244 |
$0.03 |
| D1310 |
|
1,247 |
1,240 |
$0.00 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$0.00 |