| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2140 |
|
1,988 |
1,044 |
$91K |
| D1120 |
Prophylaxis - child |
3,478 |
3,278 |
$83K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,466 |
4,225 |
$78K |
| D0120 |
Periodic oral evaluation - established patient |
3,786 |
3,586 |
$78K |
| D1110 |
Prophylaxis - adult |
1,139 |
1,039 |
$45K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
683 |
646 |
$22K |
| D0272 |
Bitewings - two radiographic images |
1,643 |
1,583 |
$20K |
| D1351 |
Sealant - per tooth |
694 |
228 |
$18K |
| D0274 |
Bitewings - four radiographic images |
449 |
412 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
79 |
41 |
$7K |
| D0330 |
Panoramic radiographic image |
139 |
133 |
$7K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
18 |
12 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
446 |
413 |
$3K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
36 |
27 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
32 |
30 |
$2K |