| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,527 |
3,450 |
$138K |
| D0120 |
Periodic oral evaluation - established patient |
3,277 |
3,211 |
$100K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
989 |
543 |
$72K |
| D1206 |
Topical application of fluoride varnish |
3,441 |
3,368 |
$55K |
| D0272 |
Bitewings - two radiographic images |
1,798 |
1,761 |
$43K |
| D0210 |
Intraoral - complete series of radiographic images |
573 |
566 |
$42K |
| D0274 |
Bitewings - four radiographic images |
898 |
876 |
$34K |
| D1351 |
Sealant - per tooth |
954 |
318 |
$33K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
448 |
320 |
$30K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,164 |
985 |
$26K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
228 |
219 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
329 |
317 |
$6K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
35 |
15 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
26 |
17 |
$1K |
| D1110 |
Prophylaxis - adult |
18 |
17 |
$696.00 |
| D0145 |
Oral evaluation for a patient under three years of age |
13 |
13 |
$401.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
15 |
12 |
$112.00 |