| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
5,028 |
4,537 |
$197K |
| D0120 |
Periodic oral evaluation - established patient |
5,338 |
4,749 |
$141K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
820 |
404 |
$99K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,168 |
3,121 |
$72K |
| D1206 |
Topical application of fluoride varnish |
2,948 |
2,210 |
$56K |
| D0272 |
Bitewings - two radiographic images |
1,589 |
1,470 |
$22K |
| D1351 |
Sealant - per tooth |
560 |
170 |
$19K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
115 |
51 |
$18K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
972 |
896 |
$17K |
| D0140 |
Limited oral evaluation - problem focused |
370 |
344 |
$16K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
146 |
70 |
$14K |
| D1330 |
|
1,524 |
1,325 |
$8K |
| D0330 |
Panoramic radiographic image |
131 |
130 |
$5K |
| D9248 |
|
25 |
25 |
$5K |
| D2335 |
|
27 |
12 |
$4K |
| D1110 |
Prophylaxis - adult |
59 |
59 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
20 |
13 |
$3K |
| D0274 |
Bitewings - four radiographic images |
69 |
69 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
26 |
26 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
13 |
12 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
45 |
42 |
$447.30 |