| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,252 |
2,180 |
$107K |
| D1206 |
Topical application of fluoride varnish |
2,773 |
2,672 |
$68K |
| D0120 |
Periodic oral evaluation - established patient |
2,351 |
2,256 |
$62K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
337 |
167 |
$35K |
| D1110 |
Prophylaxis - adult |
349 |
322 |
$19K |
| D0272 |
Bitewings - two radiographic images |
514 |
494 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
262 |
250 |
$15K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
54 |
24 |
$11K |
| D0274 |
Bitewings - four radiographic images |
255 |
241 |
$9K |
| D7140 |
Extraction, erupted tooth or exposed root |
70 |
38 |
$6K |
| D1351 |
Sealant - per tooth |
170 |
54 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
117 |
110 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
60 |
37 |
$4K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
136 |
108 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
43 |
40 |
$762.09 |