| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,571 |
1,549 |
$62K |
| D0120 |
Periodic oral evaluation - established patient |
2,128 |
2,098 |
$55K |
| D1206 |
Topical application of fluoride varnish |
2,049 |
2,020 |
$49K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
457 |
448 |
$26K |
| D1110 |
Prophylaxis - adult |
476 |
476 |
$23K |
| D0274 |
Bitewings - four radiographic images |
364 |
364 |
$13K |
| D0272 |
Bitewings - two radiographic images |
415 |
414 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
105 |
74 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
101 |
79 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
298 |
296 |
$6K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
38 |
13 |
$5K |
| D1330 |
|
428 |
428 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
109 |
106 |
$1K |
| D0240 |
|
105 |
50 |
$810.00 |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$601.25 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
17 |
17 |
$425.00 |