| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,218 |
2,181 |
$79K |
| D0120 |
Periodic oral evaluation - established patient |
1,784 |
1,762 |
$46K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,083 |
2,047 |
$35K |
| D0220 |
Intraoral - periapical first radiographic image |
1,426 |
1,391 |
$17K |
| D0272 |
Bitewings - two radiographic images |
894 |
880 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,430 |
852 |
$12K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
315 |
301 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
159 |
159 |
$6K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
55 |
28 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
66 |
40 |
$5K |
| D1351 |
Sealant - per tooth |
152 |
45 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
44 |
44 |
$2K |
| D0330 |
Panoramic radiographic image |
14 |
14 |
$501.00 |