| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,272 |
3,259 |
$104K |
| D1206 |
Topical application of fluoride varnish |
3,723 |
3,708 |
$67K |
| D0120 |
Periodic oral evaluation - established patient |
2,464 |
2,461 |
$57K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
683 |
681 |
$26K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
705 |
667 |
$22K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
143 |
96 |
$20K |
| D1354 |
|
2,366 |
772 |
$17K |
| D0272 |
Bitewings - two radiographic images |
753 |
752 |
$16K |
| D1351 |
Sealant - per tooth |
401 |
138 |
$14K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
109 |
35 |
$13K |
| D0190 |
|
627 |
597 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
773 |
766 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
353 |
352 |
$10K |
| D0350 |
|
189 |
189 |
$6K |
| D0240 |
|
286 |
286 |
$5K |
| D1110 |
Prophylaxis - adult |
100 |
100 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
25 |
15 |
$2K |
| D0274 |
Bitewings - four radiographic images |
70 |
70 |
$2K |