| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
4,955 |
4,950 |
$186K |
| D0120 |
Periodic oral evaluation - established patient |
5,349 |
5,342 |
$137K |
| D1206 |
Topical application of fluoride varnish |
5,639 |
5,631 |
$122K |
| D1110 |
Prophylaxis - adult |
849 |
848 |
$44K |
| D0272 |
Bitewings - two radiographic images |
1,648 |
1,645 |
$36K |
| D0230 |
Intraoral - periapical each additional radiographic image |
997 |
995 |
$26K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
753 |
741 |
$24K |
| D0220 |
Intraoral - periapical first radiographic image |
1,631 |
1,625 |
$21K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
117 |
68 |
$15K |
| D0330 |
Panoramic radiographic image |
159 |
159 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
64 |
36 |
$7K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
40 |
17 |
$5K |
| D1351 |
Sealant - per tooth |
135 |
40 |
$5K |
| D0274 |
Bitewings - four radiographic images |
90 |
90 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
28 |
28 |
$1K |
| D0145 |
Oral evaluation for a patient under three years of age |
26 |
26 |
$810.32 |