| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,209 |
1,202 |
$70K |
| D0120 |
Periodic oral evaluation - established patient |
1,267 |
1,265 |
$35K |
| D0330 |
Panoramic radiographic image |
351 |
351 |
$25K |
| D1206 |
Topical application of fluoride varnish |
1,278 |
1,273 |
$24K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
341 |
132 |
$23K |
| D7140 |
Extraction, erupted tooth or exposed root |
279 |
126 |
$21K |
| D0272 |
Bitewings - two radiographic images |
708 |
704 |
$15K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
121 |
50 |
$14K |
| D1110 |
Prophylaxis - adult |
248 |
248 |
$14K |
| D0140 |
Limited oral evaluation - problem focused |
215 |
213 |
$9K |
| D1351 |
Sealant - per tooth |
422 |
121 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
554 |
539 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
201 |
199 |
$5K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
159 |
153 |
$5K |
| D0274 |
Bitewings - four radiographic images |
106 |
106 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
364 |
337 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
122 |
121 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
34 |
12 |
$2K |