| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
3,847 |
3,426 |
$100K |
| D1110 |
Prophylaxis - adult |
1,934 |
1,752 |
$89K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,797 |
3,383 |
$73K |
| D1120 |
Prophylaxis - child |
1,871 |
1,631 |
$64K |
| D0272 |
Bitewings - two radiographic images |
1,738 |
1,567 |
$41K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
195 |
81 |
$27K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,012 |
800 |
$26K |
| D1351 |
Sealant - per tooth |
389 |
102 |
$11K |
| D0601 |
|
1,068 |
1,041 |
$5K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
52 |
28 |
$4K |
| D0602 |
|
850 |
828 |
$4K |
| D2140 |
|
33 |
24 |
$2K |
| D9248 |
|
21 |
13 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
19 |
12 |
$1K |
| D0603 |
|
201 |
196 |
$955.00 |