| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,199 |
1,955 |
$102K |
| D1206 |
Topical application of fluoride varnish |
1,955 |
1,728 |
$89K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
627 |
139 |
$42K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
965 |
912 |
$26K |
| D1351 |
Sealant - per tooth |
1,409 |
301 |
$26K |
| D0120 |
Periodic oral evaluation - established patient |
1,070 |
930 |
$24K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
606 |
261 |
$24K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
631 |
250 |
$19K |
| D7140 |
Extraction, erupted tooth or exposed root |
386 |
161 |
$14K |
| D0272 |
Bitewings - two radiographic images |
787 |
694 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
932 |
832 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,184 |
833 |
$10K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
687 |
554 |
$10K |
| D0330 |
Panoramic radiographic image |
282 |
248 |
$9K |
| D0274 |
Bitewings - four radiographic images |
279 |
243 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
204 |
162 |
$5K |
| D0145 |
Oral evaluation for a patient under three years of age |
250 |
224 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
233 |
226 |
$2K |
| D0170 |
|
154 |
114 |
$2K |