| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,547 |
2,546 |
$120K |
| D1120 |
Prophylaxis - child |
2,091 |
2,088 |
$96K |
| D1206 |
Topical application of fluoride varnish |
2,565 |
2,560 |
$90K |
| D1110 |
Prophylaxis - adult |
671 |
671 |
$45K |
| D0272 |
Bitewings - two radiographic images |
832 |
830 |
$35K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
158 |
80 |
$27K |
| D1351 |
Sealant - per tooth |
451 |
133 |
$19K |
| D0330 |
Panoramic radiographic image |
114 |
114 |
$13K |
| D0274 |
Bitewings - four radiographic images |
189 |
189 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
69 |
69 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
134 |
133 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
27 |
19 |
$2K |
| D1354 |
|
20 |
13 |
$676.40 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
27 |
25 |
$607.74 |