| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
4,089 |
4,055 |
$79K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,724 |
4,681 |
$69K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
646 |
269 |
$65K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,436 |
2,399 |
$63K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
890 |
520 |
$43K |
| D0120 |
Periodic oral evaluation - established patient |
2,413 |
2,397 |
$40K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,550 |
1,182 |
$38K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
550 |
364 |
$29K |
| D1110 |
Prophylaxis - adult |
727 |
711 |
$24K |
| D1351 |
Sealant - per tooth |
1,019 |
440 |
$22K |
| D0272 |
Bitewings - two radiographic images |
2,009 |
1,984 |
$20K |
| D0240 |
|
747 |
328 |
$7K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
96 |
62 |
$5K |
| D2140 |
|
84 |
61 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
48 |
26 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
320 |
307 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
29 |
13 |
$145.00 |