| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
428 |
406 |
$23K |
| D1206 |
Topical application of fluoride varnish |
419 |
398 |
$21K |
| D1351 |
Sealant - per tooth |
917 |
238 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
230 |
222 |
$7K |
| D0272 |
Bitewings - two radiographic images |
203 |
188 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
125 |
112 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
143 |
121 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
139 |
132 |
$2K |
| D1353 |
|
118 |
47 |
$2K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
19 |
13 |
$2K |
| D0274 |
Bitewings - four radiographic images |
72 |
71 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
298 |
182 |
$2K |
| D0330 |
Panoramic radiographic image |
34 |
34 |
$1K |
| D0350 |
|
37 |
29 |
$410.00 |