| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
7,991 |
7,991 |
$248K |
| D0120 |
Periodic oral evaluation - established patient |
7,582 |
7,581 |
$169K |
| D0274 |
Bitewings - four radiographic images |
4,039 |
4,039 |
$117K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,345 |
905 |
$98K |
| D1206 |
Topical application of fluoride varnish |
4,301 |
4,301 |
$78K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,060 |
1,985 |
$55K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,867 |
2,867 |
$50K |
| D1351 |
Sealant - per tooth |
2,105 |
916 |
$49K |
| D7140 |
Extraction, erupted tooth or exposed root |
653 |
394 |
$42K |
| D0140 |
Limited oral evaluation - problem focused |
1,034 |
1,017 |
$30K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
466 |
364 |
$26K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
209 |
129 |
$24K |
| D0272 |
Bitewings - two radiographic images |
821 |
821 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
394 |
394 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
146 |
119 |
$2K |
| D1110 |
Prophylaxis - adult |
54 |
54 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
162 |
161 |
$2K |