| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
6,215 |
6,214 |
$219K |
| D0120 |
Periodic oral evaluation - established patient |
5,598 |
5,598 |
$137K |
| D1206 |
Topical application of fluoride varnish |
3,376 |
3,376 |
$96K |
| D1351 |
Sealant - per tooth |
2,217 |
490 |
$82K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,628 |
3,627 |
$47K |
| D0272 |
Bitewings - two radiographic images |
2,858 |
2,857 |
$41K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,423 |
1,423 |
$34K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
577 |
307 |
$34K |
| D1110 |
Prophylaxis - adult |
745 |
745 |
$32K |
| D0330 |
Panoramic radiographic image |
928 |
927 |
$30K |
| D0274 |
Bitewings - four radiographic images |
590 |
590 |
$15K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
212 |
158 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
541 |
541 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
263 |
263 |
$2K |
| D2394 |
|
18 |
13 |
$2K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
16 |
12 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$172.10 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
364 |
338 |
$0.00 |