| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,124 |
2,119 |
$90K |
| D1206 |
Topical application of fluoride varnish |
2,091 |
2,086 |
$56K |
| D0120 |
Periodic oral evaluation - established patient |
1,736 |
1,730 |
$51K |
| D1351 |
Sealant - per tooth |
763 |
338 |
$43K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
627 |
477 |
$39K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
577 |
546 |
$38K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
417 |
348 |
$17K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
411 |
410 |
$11K |
| D0274 |
Bitewings - four radiographic images |
578 |
574 |
$10K |
| D7140 |
Extraction, erupted tooth or exposed root |
144 |
117 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
910 |
900 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
876 |
683 |
$5K |
| D0272 |
Bitewings - two radiographic images |
395 |
395 |
$4K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
26 |
24 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
148 |
148 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
15 |
15 |
$1K |