| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,549 |
1,546 |
$88K |
| D0120 |
Periodic oral evaluation - established patient |
1,379 |
1,378 |
$36K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
484 |
268 |
$34K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
268 |
110 |
$31K |
| D1206 |
Topical application of fluoride varnish |
1,622 |
1,620 |
$29K |
| D7140 |
Extraction, erupted tooth or exposed root |
359 |
152 |
$28K |
| D0272 |
Bitewings - two radiographic images |
869 |
868 |
$18K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
321 |
200 |
$18K |
| D0330 |
Panoramic radiographic image |
236 |
236 |
$16K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
475 |
463 |
$15K |
| D1110 |
Prophylaxis - adult |
233 |
232 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
395 |
392 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
210 |
208 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
236 |
236 |
$3K |
| D1351 |
Sealant - per tooth |
37 |
16 |
$702.00 |