| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
688 |
670 |
$34K |
| D0120 |
Periodic oral evaluation - established patient |
1,103 |
1,081 |
$29K |
| D1110 |
Prophylaxis - adult |
414 |
408 |
$21K |
| D1206 |
Topical application of fluoride varnish |
741 |
721 |
$13K |
| D0330 |
Panoramic radiographic image |
169 |
168 |
$10K |
| D0272 |
Bitewings - two radiographic images |
546 |
537 |
$10K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
62 |
25 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
70 |
40 |
$5K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
120 |
102 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
129 |
127 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
15 |
12 |
$731.11 |
| D0220 |
Intraoral - periapical first radiographic image |
42 |
40 |
$499.93 |
| D9986 |
|
30 |
28 |
$84.00 |