| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,784 |
1,754 |
$83K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
557 |
163 |
$61K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,531 |
1,499 |
$38K |
| D7140 |
Extraction, erupted tooth or exposed root |
411 |
154 |
$20K |
| D1206 |
Topical application of fluoride varnish |
1,119 |
1,100 |
$16K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
210 |
135 |
$14K |
| D1208 |
Topical application of fluoride, excluding varnish |
855 |
839 |
$12K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
330 |
317 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
514 |
504 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
196 |
123 |
$11K |
| D0272 |
Bitewings - two radiographic images |
596 |
586 |
$10K |
| D1110 |
Prophylaxis - adult |
128 |
123 |
$6K |
| D1351 |
Sealant - per tooth |
286 |
99 |
$5K |
| D0274 |
Bitewings - four radiographic images |
185 |
182 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
62 |
59 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
16 |
15 |
$961.88 |
| D0330 |
Panoramic radiographic image |
26 |
25 |
$951.60 |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$124.18 |