| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,902 |
3,851 |
$180K |
| D1351 |
Sealant - per tooth |
4,731 |
1,130 |
$171K |
| D0120 |
Periodic oral evaluation - established patient |
4,258 |
4,189 |
$131K |
| D1206 |
Topical application of fluoride varnish |
2,687 |
2,631 |
$67K |
| D1110 |
Prophylaxis - adult |
1,003 |
981 |
$63K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,401 |
2,381 |
$56K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
438 |
245 |
$56K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
796 |
793 |
$44K |
| D0272 |
Bitewings - two radiographic images |
2,555 |
2,521 |
$41K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
158 |
64 |
$28K |
| D0330 |
Panoramic radiographic image |
609 |
603 |
$28K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
259 |
163 |
$24K |
| D0274 |
Bitewings - four radiographic images |
1,034 |
1,013 |
$24K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
869 |
802 |
$17K |
| D1330 |
|
2,024 |
2,004 |
$12K |