| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,181 |
1,179 |
$63K |
| D1351 |
Sealant - per tooth |
2,467 |
494 |
$56K |
| D1206 |
Topical application of fluoride varnish |
1,208 |
1,207 |
$37K |
| D0120 |
Periodic oral evaluation - established patient |
1,054 |
1,052 |
$35K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
339 |
181 |
$23K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
283 |
282 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
1,095 |
1,089 |
$7K |
| D0272 |
Bitewings - two radiographic images |
583 |
581 |
$7K |
| D0603 |
|
1,199 |
1,197 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
181 |
174 |
$6K |
| D0274 |
Bitewings - four radiographic images |
342 |
340 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
914 |
909 |
$4K |
| D9920 |
|
162 |
157 |
$3K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
22 |
12 |
$3K |
| D0330 |
Panoramic radiographic image |
44 |
44 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
22 |
15 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
29 |
29 |
$952.00 |