| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,795 |
1,764 |
$30K |
| D1206 |
Topical application of fluoride varnish |
1,989 |
1,959 |
$20K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
646 |
632 |
$14K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
466 |
402 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
1,099 |
1,087 |
$8K |
| D0272 |
Bitewings - two radiographic images |
777 |
766 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
112 |
66 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
105 |
38 |
$5K |
| D0240 |
|
455 |
228 |
$3K |
| D0330 |
Panoramic radiographic image |
153 |
151 |
$3K |
| D1351 |
Sealant - per tooth |
327 |
96 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
417 |
402 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
182 |
178 |
$894.20 |
| D0145 |
Oral evaluation for a patient under three years of age |
44 |
42 |
$759.80 |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
81 |
34 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
14 |
14 |
$0.00 |
| D1354 |
|
200 |
74 |
$0.00 |
| D1110 |
Prophylaxis - adult |
72 |
72 |
$0.00 |
| D0140 |
Limited oral evaluation - problem focused |
15 |
15 |
$0.00 |