| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,244 |
2,143 |
$71K |
| D0120 |
Periodic oral evaluation - established patient |
2,027 |
1,935 |
$50K |
| D0145 |
Oral evaluation for a patient under three years of age |
326 |
323 |
$44K |
| D1351 |
Sealant - per tooth |
1,686 |
303 |
$41K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,437 |
1,615 |
$30K |
| D0272 |
Bitewings - two radiographic images |
1,560 |
1,500 |
$29K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,816 |
1,731 |
$23K |
| D0220 |
Intraoral - periapical first radiographic image |
2,137 |
1,990 |
$20K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
638 |
603 |
$20K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
72 |
14 |
$10K |
| D1206 |
Topical application of fluoride varnish |
435 |
415 |
$6K |
| D1110 |
Prophylaxis - adult |
94 |
87 |
$5K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
197 |
177 |
$4K |
| D0274 |
Bitewings - four radiographic images |
159 |
148 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
49 |
28 |
$4K |
| D0330 |
Panoramic radiographic image |
75 |
75 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
23 |
16 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$225.36 |
| D0350 |
|
20 |
20 |
$36.76 |
| D0603 |
|
3,403 |
3,288 |
$0.00 |
| D1310 |
|
222 |
207 |
$0.00 |