| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,060 |
1,053 |
$35K |
| D0274 |
Bitewings - four radiographic images |
844 |
841 |
$26K |
| D1206 |
Topical application of fluoride varnish |
1,047 |
1,042 |
$20K |
| D0220 |
Intraoral - periapical first radiographic image |
911 |
906 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
293 |
289 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
906 |
894 |
$9K |
| D0330 |
Panoramic radiographic image |
291 |
289 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
97 |
56 |
$7K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
50 |
25 |
$6K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
190 |
187 |
$5K |
| D1351 |
Sealant - per tooth |
29 |
12 |
$748.38 |
| D0272 |
Bitewings - two radiographic images |
14 |
14 |
$303.28 |
| D0120 |
Periodic oral evaluation - established patient |
13 |
12 |
$277.42 |