| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
890 |
882 |
$28K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
613 |
603 |
$14K |
| D1206 |
Topical application of fluoride varnish |
836 |
827 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
607 |
606 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,207 |
570 |
$11K |
| D0330 |
Panoramic radiographic image |
155 |
155 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
713 |
699 |
$6K |
| D0272 |
Bitewings - two radiographic images |
316 |
316 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
115 |
54 |
$3K |
| D1110 |
Prophylaxis - adult |
83 |
83 |
$3K |
| D9310 |
|
30 |
30 |
$2K |
| D0274 |
Bitewings - four radiographic images |
119 |
119 |
$2K |
| D1351 |
Sealant - per tooth |
65 |
13 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
79 |
70 |
$404.88 |
| D0210 |
Intraoral - complete series of radiographic images |
26 |
26 |
$0.00 |
| D0140 |
Limited oral evaluation - problem focused |
40 |
38 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
167 |
62 |
$0.00 |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
32 |
12 |
$0.00 |