| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,825 |
1,788 |
$51K |
| D0120 |
Periodic oral evaluation - established patient |
2,008 |
1,978 |
$41K |
| D1206 |
Topical application of fluoride varnish |
2,315 |
2,271 |
$38K |
| D1110 |
Prophylaxis - adult |
492 |
486 |
$21K |
| D1351 |
Sealant - per tooth |
926 |
138 |
$21K |
| D0274 |
Bitewings - four radiographic images |
364 |
360 |
$11K |
| D0272 |
Bitewings - two radiographic images |
576 |
567 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
297 |
285 |
$8K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
68 |
25 |
$8K |
| D0330 |
Panoramic radiographic image |
121 |
118 |
$6K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
127 |
122 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
53 |
52 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
15 |
14 |
$171.80 |