| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,677 |
3,616 |
$113K |
| D0120 |
Periodic oral evaluation - established patient |
3,715 |
3,637 |
$74K |
| D1206 |
Topical application of fluoride varnish |
4,212 |
4,129 |
$63K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
598 |
330 |
$42K |
| D0272 |
Bitewings - two radiographic images |
1,698 |
1,684 |
$30K |
| D1351 |
Sealant - per tooth |
1,116 |
346 |
$24K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
644 |
593 |
$14K |
| D1110 |
Prophylaxis - adult |
383 |
380 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
302 |
300 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
126 |
55 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
140 |
100 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
535 |
514 |
$6K |
| D1354 |
|
225 |
59 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
96 |
94 |
$3K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
30 |
12 |
$3K |
| D0274 |
Bitewings - four radiographic images |
87 |
87 |
$2K |
| D0240 |
|
124 |
101 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
71 |
68 |
$861.95 |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$724.23 |