| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,823 |
3,797 |
$127K |
| D1206 |
Topical application of fluoride varnish |
4,429 |
4,397 |
$92K |
| D0120 |
Periodic oral evaluation - established patient |
3,825 |
3,795 |
$77K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
953 |
898 |
$32K |
| D0272 |
Bitewings - two radiographic images |
1,491 |
1,481 |
$30K |
| D1110 |
Prophylaxis - adult |
493 |
487 |
$24K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
603 |
601 |
$18K |
| D0330 |
Panoramic radiographic image |
172 |
172 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
103 |
76 |
$8K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
51 |
13 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
72 |
50 |
$5K |
| D0274 |
Bitewings - four radiographic images |
107 |
107 |
$3K |
| D1351 |
Sealant - per tooth |
48 |
12 |
$2K |
| D0240 |
|
115 |
64 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
111 |
110 |
$1K |