| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,477 |
2,413 |
$61K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,707 |
2,653 |
$44K |
| D0120 |
Periodic oral evaluation - established patient |
2,467 |
2,404 |
$40K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
223 |
63 |
$26K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
698 |
660 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,921 |
565 |
$14K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
295 |
191 |
$13K |
| D1354 |
|
152 |
33 |
$11K |
| D1110 |
Prophylaxis - adult |
271 |
262 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
272 |
264 |
$7K |
| D0272 |
Bitewings - two radiographic images |
428 |
408 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
979 |
917 |
$6K |
| D1351 |
Sealant - per tooth |
211 |
45 |
$5K |
| D0330 |
Panoramic radiographic image |
59 |
57 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
273 |
130 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
37 |
24 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
40 |
38 |
$889.92 |
| D0274 |
Bitewings - four radiographic images |
13 |
12 |
$395.04 |
| D1999 |
|
36 |
35 |
$0.00 |