| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
377 |
365 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
301 |
293 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
883 |
368 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
300 |
284 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
183 |
176 |
$2K |
| D0272 |
Bitewings - two radiographic images |
209 |
204 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
66 |
65 |
$2K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
57 |
15 |
$1K |
| D1206 |
Topical application of fluoride varnish |
73 |
72 |
$806.40 |
| D1351 |
Sealant - per tooth |
47 |
12 |
$679.68 |
| D0330 |
Panoramic radiographic image |
35 |
35 |
$642.60 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
25 |
13 |
$444.60 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
52 |
47 |
$313.99 |
| D1110 |
Prophylaxis - adult |
24 |
24 |
$0.00 |
| D9999 |
Unspecified adjunctive procedure, by report |
18 |
18 |
$0.00 |