| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,673 |
1,594 |
$45K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
331 |
79 |
$31K |
| D0120 |
Periodic oral evaluation - established patient |
1,541 |
1,469 |
$30K |
| D1206 |
Topical application of fluoride varnish |
2,015 |
1,888 |
$24K |
| D0272 |
Bitewings - two radiographic images |
884 |
853 |
$12K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
200 |
192 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
70 |
70 |
$2K |
| D1351 |
Sealant - per tooth |
88 |
42 |
$2K |
| D0240 |
|
67 |
38 |
$667.18 |
| D0220 |
Intraoral - periapical first radiographic image |
70 |
69 |
$561.55 |