| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
4,483 |
4,361 |
$175K |
| D0120 |
Periodic oral evaluation - established patient |
4,900 |
4,777 |
$130K |
| D1351 |
Sealant - per tooth |
2,439 |
1,265 |
$119K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,337 |
2,230 |
$57K |
| D1206 |
Topical application of fluoride varnish |
2,152 |
2,137 |
$54K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
672 |
601 |
$21K |
| D0272 |
Bitewings - two radiographic images |
843 |
810 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
112 |
94 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
100 |
100 |
$2K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
17 |
13 |
$1K |
| D0330 |
Panoramic radiographic image |
37 |
36 |
$678.00 |
| D0220 |
Intraoral - periapical first radiographic image |
114 |
107 |
$576.40 |
| D0274 |
Bitewings - four radiographic images |
18 |
15 |
$304.20 |
| D0230 |
Intraoral - periapical each additional radiographic image |
12 |
12 |
$56.90 |
| D0601 |
|
1,259 |
1,252 |
$0.00 |
| D0603 |
|
352 |
352 |
$0.00 |
| D0602 |
|
639 |
635 |
$0.00 |