| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,712 |
1,701 |
$72K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
543 |
530 |
$38K |
| D0120 |
Periodic oral evaluation - established patient |
1,162 |
1,154 |
$33K |
| D1206 |
Topical application of fluoride varnish |
1,201 |
1,195 |
$32K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
583 |
582 |
$15K |
| D1208 |
Topical application of fluoride, excluding varnish |
406 |
401 |
$11K |
| D1351 |
Sealant - per tooth |
163 |
83 |
$9K |
| D0272 |
Bitewings - two radiographic images |
725 |
721 |
$8K |
| D0274 |
Bitewings - four radiographic images |
268 |
268 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
658 |
650 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
134 |
134 |
$4K |
| D0330 |
Panoramic radiographic image |
162 |
162 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
332 |
322 |
$2K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
13 |
12 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
16 |
12 |
$1K |