| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,905 |
2,807 |
$81K |
| D1206 |
Topical application of fluoride varnish |
2,858 |
2,766 |
$49K |
| D0120 |
Periodic oral evaluation - established patient |
2,292 |
2,227 |
$46K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
328 |
129 |
$33K |
| D0272 |
Bitewings - two radiographic images |
1,380 |
1,324 |
$22K |
| D1351 |
Sealant - per tooth |
723 |
209 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
414 |
398 |
$13K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
761 |
671 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
47 |
29 |
$4K |
| D0330 |
Panoramic radiographic image |
91 |
90 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
123 |
120 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
135 |
129 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
15 |
13 |
$995.91 |
| D1110 |
Prophylaxis - adult |
19 |
16 |
$609.12 |
| D0240 |
|
36 |
25 |
$395.17 |
| D0145 |
Oral evaluation for a patient under three years of age |
13 |
13 |
$384.63 |