| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
713 |
700 |
$30K |
| D0120 |
Periodic oral evaluation - established patient |
547 |
537 |
$16K |
| D1206 |
Topical application of fluoride varnish |
689 |
674 |
$14K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
71 |
17 |
$8K |
| D0272 |
Bitewings - two radiographic images |
263 |
261 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
122 |
120 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
462 |
136 |
$4K |
| D0603 |
|
699 |
681 |
$4K |
| D0240 |
|
162 |
87 |
$3K |
| D1351 |
Sealant - per tooth |
68 |
18 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
186 |
178 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
80 |
77 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
41 |
39 |
$1K |
| D0274 |
Bitewings - four radiographic images |
32 |
29 |
$867.10 |
| D0330 |
Panoramic radiographic image |
55 |
53 |
$837.20 |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$800.40 |
| D1110 |
Prophylaxis - adult |
16 |
14 |
$702.65 |
| D0602 |
|
28 |
28 |
$113.85 |