| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
4,658 |
4,637 |
$158K |
| D1206 |
Topical application of fluoride varnish |
7,121 |
7,088 |
$138K |
| D0120 |
Periodic oral evaluation - established patient |
5,394 |
5,368 |
$130K |
| D1110 |
Prophylaxis - adult |
1,416 |
1,407 |
$65K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
516 |
330 |
$53K |
| D1351 |
Sealant - per tooth |
1,314 |
378 |
$46K |
| D0272 |
Bitewings - two radiographic images |
1,870 |
1,861 |
$39K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
302 |
183 |
$38K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,045 |
1,014 |
$32K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
244 |
101 |
$31K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
533 |
533 |
$21K |
| D0330 |
Panoramic radiographic image |
385 |
385 |
$20K |
| D0230 |
Intraoral - periapical each additional radiographic image |
558 |
558 |
$19K |
| D0220 |
Intraoral - periapical first radiographic image |
860 |
854 |
$11K |
| D0145 |
Oral evaluation for a patient under three years of age |
324 |
324 |
$10K |
| D0274 |
Bitewings - four radiographic images |
222 |
222 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
132 |
132 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
24 |
12 |
$2K |