| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,207 |
2,159 |
$76K |
| D1351 |
Sealant - per tooth |
2,835 |
599 |
$75K |
| D0272 |
Bitewings - two radiographic images |
1,965 |
1,921 |
$44K |
| D0120 |
Periodic oral evaluation - established patient |
1,433 |
1,407 |
$40K |
| D0145 |
Oral evaluation for a patient under three years of age |
270 |
266 |
$37K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,538 |
2,481 |
$35K |
| D0220 |
Intraoral - periapical first radiographic image |
2,649 |
2,571 |
$32K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,700 |
2,439 |
$30K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
207 |
69 |
$29K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
695 |
663 |
$22K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
532 |
492 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
124 |
63 |
$11K |
| D0274 |
Bitewings - four radiographic images |
57 |
55 |
$2K |
| D0603 |
|
3,603 |
3,525 |
$0.00 |