| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,606 |
2,578 |
$65K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,294 |
2,276 |
$41K |
| D0120 |
Periodic oral evaluation - established patient |
1,936 |
1,922 |
$28K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
800 |
785 |
$23K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
322 |
235 |
$23K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
976 |
920 |
$22K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
278 |
179 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,661 |
608 |
$10K |
| D0272 |
Bitewings - two radiographic images |
534 |
526 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
817 |
804 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
42 |
26 |
$3K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
15 |
13 |
$3K |
| D1351 |
Sealant - per tooth |
106 |
39 |
$2K |
| D1110 |
Prophylaxis - adult |
50 |
50 |
$2K |
| D9920 |
|
52 |
50 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
174 |
168 |
$1K |
| D0274 |
Bitewings - four radiographic images |
24 |
24 |
$761.76 |
| D1206 |
Topical application of fluoride varnish |
308 |
299 |
$702.78 |