| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,337 |
1,312 |
$70K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
456 |
227 |
$48K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
751 |
737 |
$45K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,294 |
1,271 |
$39K |
| D0120 |
Periodic oral evaluation - established patient |
750 |
734 |
$22K |
| D1351 |
Sealant - per tooth |
393 |
127 |
$17K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
61 |
33 |
$13K |
| D0274 |
Bitewings - four radiographic images |
269 |
264 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
523 |
498 |
$10K |
| D0272 |
Bitewings - two radiographic images |
298 |
293 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
552 |
428 |
$8K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
358 |
303 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
20 |
14 |
$2K |
| D1206 |
Topical application of fluoride varnish |
44 |
43 |
$1K |
| D1110 |
Prophylaxis - adult |
14 |
14 |
$1K |