| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
5,000 |
4,944 |
$135K |
| D0120 |
Periodic oral evaluation - established patient |
6,143 |
6,091 |
$107K |
| D1208 |
Topical application of fluoride, excluding varnish |
6,187 |
6,122 |
$89K |
| D0330 |
Panoramic radiographic image |
1,038 |
1,023 |
$47K |
| D0272 |
Bitewings - two radiographic images |
2,614 |
2,583 |
$44K |
| D1110 |
Prophylaxis - adult |
1,187 |
1,181 |
$40K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
316 |
236 |
$22K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
663 |
643 |
$14K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
721 |
680 |
$13K |
| D1351 |
Sealant - per tooth |
461 |
116 |
$11K |
| D1206 |
Topical application of fluoride varnish |
576 |
572 |
$10K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
57 |
43 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
33 |
12 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
17 |
14 |
$826.00 |
| D0220 |
Intraoral - periapical first radiographic image |
51 |
50 |
$550.00 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$377.00 |