| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,583 |
2,560 |
$109K |
| D0120 |
Periodic oral evaluation - established patient |
2,959 |
2,934 |
$86K |
| D1206 |
Topical application of fluoride varnish |
3,222 |
3,197 |
$80K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
663 |
417 |
$79K |
| D1351 |
Sealant - per tooth |
2,177 |
639 |
$71K |
| D9941 |
|
445 |
437 |
$45K |
| D1110 |
Prophylaxis - adult |
454 |
453 |
$27K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
240 |
170 |
$22K |
| D0330 |
Panoramic radiographic image |
418 |
416 |
$18K |
| D0272 |
Bitewings - two radiographic images |
1,093 |
1,081 |
$16K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
887 |
818 |
$16K |
| D1330 |
|
1,753 |
1,735 |
$10K |
| D0274 |
Bitewings - four radiographic images |
478 |
471 |
$10K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
31 |
26 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
51 |
51 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
50 |
47 |
$2K |
| D3120 |
|
54 |
39 |
$2K |