| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,505 |
1,480 |
$79K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
430 |
247 |
$30K |
| D1206 |
Topical application of fluoride varnish |
1,559 |
1,541 |
$27K |
| D0120 |
Periodic oral evaluation - established patient |
1,001 |
998 |
$23K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
669 |
649 |
$21K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
169 |
115 |
$20K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
500 |
457 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,533 |
535 |
$13K |
| D0330 |
Panoramic radiographic image |
219 |
218 |
$12K |
| D0272 |
Bitewings - two radiographic images |
590 |
590 |
$12K |
| D7140 |
Extraction, erupted tooth or exposed root |
155 |
95 |
$9K |
| D1351 |
Sealant - per tooth |
374 |
131 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
680 |
673 |
$8K |
| D1110 |
Prophylaxis - adult |
105 |
104 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
93 |
65 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
97 |
95 |
$3K |
| D0274 |
Bitewings - four radiographic images |
90 |
89 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
25 |
15 |
$111.95 |