| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,186 |
1,135 |
$42K |
| D1206 |
Topical application of fluoride varnish |
1,355 |
1,291 |
$23K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
520 |
495 |
$19K |
| D0120 |
Periodic oral evaluation - established patient |
770 |
742 |
$18K |
| D0272 |
Bitewings - two radiographic images |
684 |
651 |
$11K |
| D0330 |
Panoramic radiographic image |
254 |
246 |
$8K |
| D1351 |
Sealant - per tooth |
315 |
66 |
$7K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
46 |
12 |
$4K |
| D1110 |
Prophylaxis - adult |
59 |
59 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
40 |
40 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
31 |
25 |
$629.14 |
| D1354 |
|
36 |
13 |
$370.42 |
| D0240 |
|
30 |
12 |
$308.26 |