| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,581 |
3,563 |
$156K |
| D1206 |
Topical application of fluoride varnish |
3,703 |
3,683 |
$113K |
| D1351 |
Sealant - per tooth |
5,432 |
1,216 |
$103K |
| D0120 |
Periodic oral evaluation - established patient |
2,820 |
2,802 |
$69K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
931 |
548 |
$63K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,189 |
1,147 |
$29K |
| D0272 |
Bitewings - two radiographic images |
1,863 |
1,853 |
$18K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
332 |
236 |
$18K |
| D1353 |
|
1,981 |
453 |
$17K |
| D0603 |
|
2,411 |
2,397 |
$17K |
| D7140 |
Extraction, erupted tooth or exposed root |
217 |
136 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
3,147 |
3,116 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
541 |
539 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,980 |
2,941 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
146 |
145 |
$6K |
| D0274 |
Bitewings - four radiographic images |
437 |
435 |
$5K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
39 |
25 |
$4K |
| D0145 |
Oral evaluation for a patient under three years of age |
79 |
79 |
$3K |
| D1110 |
Prophylaxis - adult |
108 |
106 |
$3K |
| D9920 |
|
80 |
76 |
$2K |
| D0601 |
|
217 |
216 |
$2K |