| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,266 |
1,258 |
$43K |
| D0120 |
Periodic oral evaluation - established patient |
1,175 |
1,169 |
$28K |
| D1206 |
Topical application of fluoride varnish |
1,419 |
1,406 |
$27K |
| D0272 |
Bitewings - two radiographic images |
382 |
380 |
$6K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
47 |
12 |
$5K |
| D1351 |
Sealant - per tooth |
127 |
26 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
146 |
142 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
76 |
75 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
151 |
150 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
21 |
13 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
119 |
74 |
$964.20 |
| D0330 |
Panoramic radiographic image |
16 |
16 |
$456.90 |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$358.20 |