| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,113 |
1,106 |
$32K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,487 |
1,465 |
$22K |
| D0120 |
Periodic oral evaluation - established patient |
1,067 |
1,054 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
298 |
291 |
$9K |
| D1999 |
|
416 |
362 |
$8K |
| D0272 |
Bitewings - two radiographic images |
346 |
343 |
$6K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
89 |
28 |
$6K |
| D1110 |
Prophylaxis - adult |
124 |
120 |
$4K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
135 |
112 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
200 |
193 |
$2K |
| D0330 |
Panoramic radiographic image |
30 |
30 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
50 |
46 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
52 |
51 |
$477.20 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$308.00 |