| Code | Description | Claims | Beneficiaries | Total Paid |
| D0120 |
Periodic oral evaluation - established patient |
1,340 |
1,319 |
$37K |
| D1120 |
Prophylaxis - child |
1,014 |
985 |
$35K |
| D0145 |
Oral evaluation for a patient under three years of age |
242 |
241 |
$33K |
| D1351 |
Sealant - per tooth |
971 |
153 |
$25K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
211 |
56 |
$24K |
| D1110 |
Prophylaxis - adult |
367 |
367 |
$20K |
| D1206 |
Topical application of fluoride varnish |
1,275 |
1,249 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
1,308 |
1,245 |
$15K |
| D0272 |
Bitewings - two radiographic images |
693 |
670 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,363 |
1,090 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
219 |
209 |
$7K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
224 |
210 |
$6K |
| D0274 |
Bitewings - four radiographic images |
159 |
159 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
33 |
13 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
168 |
164 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
25 |
14 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
71 |
70 |
$1K |
| D9420 |
|
13 |
13 |
$360.31 |
| D1999 |
|
293 |
272 |
$0.00 |
| D0603 |
|
1,983 |
1,963 |
$0.00 |