| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
4,217 |
3,961 |
$196K |
| D0120 |
Periodic oral evaluation - established patient |
3,917 |
3,685 |
$86K |
| D1206 |
Topical application of fluoride varnish |
3,498 |
3,296 |
$50K |
| D0272 |
Bitewings - two radiographic images |
1,066 |
960 |
$17K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
116 |
25 |
$12K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
427 |
350 |
$12K |
| D1208 |
Topical application of fluoride, excluding varnish |
824 |
767 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
274 |
256 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
93 |
56 |
$6K |
| D1351 |
Sealant - per tooth |
295 |
86 |
$6K |
| D0274 |
Bitewings - four radiographic images |
175 |
168 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
564 |
474 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
20 |
12 |
$1K |
| D0330 |
Panoramic radiographic image |
28 |
28 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
113 |
74 |
$685.62 |