| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
723 |
723 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
399 |
399 |
$8K |
| D9920 |
|
624 |
563 |
$6K |
| D1206 |
Topical application of fluoride varnish |
743 |
742 |
$5K |
| D9310 |
|
162 |
162 |
$5K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
374 |
339 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
461 |
449 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
417 |
359 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
58 |
26 |
$1K |
| D0272 |
Bitewings - two radiographic images |
53 |
53 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
393 |
392 |
$707.40 |
| D0240 |
|
163 |
92 |
$398.75 |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
42 |
26 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
178 |
178 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
280 |
131 |
$0.00 |
| D1351 |
Sealant - per tooth |
134 |
45 |
$0.00 |
| D3120 |
|
102 |
43 |
$0.00 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
87 |
53 |
$0.00 |
| D9994 |
|
209 |
209 |
$0.00 |
| D0140 |
Limited oral evaluation - problem focused |
33 |
30 |
$0.00 |
| D2335 |
|
21 |
12 |
$0.00 |