| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,406 |
1,137 |
$46K |
| D1206 |
Topical application of fluoride varnish |
1,492 |
1,225 |
$39K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
598 |
206 |
$30K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
797 |
681 |
$21K |
| D0272 |
Bitewings - two radiographic images |
1,117 |
918 |
$15K |
| D7140 |
Extraction, erupted tooth or exposed root |
406 |
187 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
624 |
495 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
231 |
107 |
$10K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
611 |
511 |
$8K |
| D0330 |
Panoramic radiographic image |
268 |
210 |
$8K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
172 |
68 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
206 |
185 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
627 |
461 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
753 |
460 |
$3K |
| D0603 |
|
724 |
630 |
$2K |
| D1351 |
Sealant - per tooth |
170 |
34 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
47 |
19 |
$1K |
| D9310 |
|
44 |
39 |
$1K |
| D9248 |
|
16 |
15 |
$1K |
| D0601 |
|
406 |
359 |
$1K |
| D0274 |
Bitewings - four radiographic images |
67 |
49 |
$1K |
| D0240 |
|
63 |
30 |
$452.48 |