| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,274 |
2,124 |
$76K |
| D1206 |
Topical application of fluoride varnish |
2,781 |
2,598 |
$58K |
| D0120 |
Periodic oral evaluation - established patient |
2,113 |
1,970 |
$46K |
| D1354 |
|
570 |
87 |
$42K |
| D0272 |
Bitewings - two radiographic images |
716 |
668 |
$17K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
103 |
26 |
$15K |
| D1351 |
Sealant - per tooth |
471 |
61 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,288 |
473 |
$11K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
227 |
209 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
600 |
528 |
$6K |
| D1110 |
Prophylaxis - adult |
123 |
110 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
145 |
136 |
$5K |
| D0330 |
Panoramic radiographic image |
45 |
40 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
53 |
42 |
$1K |
| D9920 |
|
26 |
24 |
$935.00 |
| D0240 |
|
26 |
12 |
$509.22 |
| D1999 |
|
14 |
14 |
$0.00 |