| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,377 |
1,364 |
$39K |
| D0120 |
Periodic oral evaluation - established patient |
1,534 |
1,517 |
$31K |
| D0272 |
Bitewings - two radiographic images |
1,313 |
1,301 |
$25K |
| D1206 |
Topical application of fluoride varnish |
1,309 |
1,297 |
$21K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
181 |
101 |
$20K |
| D1351 |
Sealant - per tooth |
817 |
325 |
$19K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
794 |
662 |
$16K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
148 |
112 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
320 |
319 |
$5K |
| D1110 |
Prophylaxis - adult |
100 |
100 |
$4K |
| D0274 |
Bitewings - four radiographic images |
40 |
40 |
$1K |
| D0240 |
|
44 |
26 |
$774.00 |