| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,227 |
2,216 |
$58K |
| D1206 |
Topical application of fluoride varnish |
2,816 |
2,804 |
$54K |
| D0120 |
Periodic oral evaluation - established patient |
2,053 |
2,042 |
$43K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
471 |
156 |
$29K |
| D0272 |
Bitewings - two radiographic images |
875 |
869 |
$15K |
| D1110 |
Prophylaxis - adult |
321 |
320 |
$13K |
| D1351 |
Sealant - per tooth |
481 |
91 |
$12K |
| D9248 |
|
91 |
91 |
$11K |
| D0603 |
|
967 |
956 |
$9K |
| D1330 |
|
1,494 |
1,481 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
184 |
184 |
$4K |
| D0145 |
Oral evaluation for a patient under three years of age |
133 |
132 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
306 |
306 |
$3K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
26 |
12 |
$3K |
| D0602 |
|
258 |
258 |
$3K |
| D0601 |
|
189 |
189 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
148 |
148 |
$1K |
| D0274 |
Bitewings - four radiographic images |
39 |
39 |
$1K |
| D0330 |
Panoramic radiographic image |
25 |
25 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
23 |
20 |
$765.20 |
| D9110 |
|
12 |
12 |
$426.66 |
| D1310 |
|
524 |
513 |
$12.00 |