| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,420 |
1,417 |
$54K |
| D0120 |
Periodic oral evaluation - established patient |
1,274 |
1,271 |
$34K |
| D1208 |
Topical application of fluoride, excluding varnish |
944 |
944 |
$17K |
| D0272 |
Bitewings - two radiographic images |
632 |
631 |
$12K |
| D1351 |
Sealant - per tooth |
346 |
107 |
$11K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
372 |
343 |
$9K |
| D1206 |
Topical application of fluoride varnish |
320 |
318 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
66 |
42 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
87 |
87 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
194 |
181 |
$2K |
| D1354 |
|
696 |
227 |
$2K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
15 |
12 |
$1K |
| D0240 |
|
49 |
26 |
$688.00 |
| D0330 |
Panoramic radiographic image |
14 |
14 |
$520.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
37 |
16 |
$324.00 |