| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,769 |
3,737 |
$157K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,701 |
566 |
$102K |
| D1110 |
Prophylaxis - adult |
1,796 |
1,782 |
$85K |
| D0330 |
Panoramic radiographic image |
1,299 |
1,284 |
$71K |
| D9248 |
|
208 |
197 |
$52K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
814 |
531 |
$36K |
| D0120 |
Periodic oral evaluation - established patient |
4,884 |
4,845 |
$29K |
| D7140 |
Extraction, erupted tooth or exposed root |
587 |
301 |
$25K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
679 |
675 |
$25K |
| D0210 |
Intraoral - complete series of radiographic images |
306 |
296 |
$19K |
| D1351 |
Sealant - per tooth |
1,587 |
517 |
$14K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,606 |
1,439 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
5,268 |
5,223 |
$12K |
| D0140 |
Limited oral evaluation - problem focused |
484 |
470 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
72 |
49 |
$5K |
| D0274 |
Bitewings - four radiographic images |
718 |
711 |
$3K |
| D0272 |
Bitewings - two radiographic images |
1,775 |
1,763 |
$2K |
| D0240 |
|
277 |
263 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
617 |
594 |
$218.05 |