| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,420 |
1,415 |
$47K |
| D1206 |
Topical application of fluoride varnish |
2,204 |
2,198 |
$41K |
| D0120 |
Periodic oral evaluation - established patient |
1,670 |
1,667 |
$39K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
174 |
91 |
$22K |
| D1110 |
Prophylaxis - adult |
420 |
419 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
409 |
406 |
$17K |
| D0272 |
Bitewings - two radiographic images |
731 |
728 |
$16K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
331 |
322 |
$11K |
| D0330 |
Panoramic radiographic image |
120 |
120 |
$6K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
27 |
12 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
28 |
24 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
226 |
224 |
$3K |
| D1351 |
Sealant - per tooth |
77 |
25 |
$3K |
| D0274 |
Bitewings - four radiographic images |
75 |
74 |
$2K |
| D0240 |
|
46 |
43 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
38 |
38 |
$944.65 |
| D1354 |
|
104 |
28 |
$795.32 |