| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,254 |
1,190 |
$41K |
| D1206 |
Topical application of fluoride varnish |
1,653 |
1,579 |
$35K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
962 |
905 |
$27K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
232 |
82 |
$24K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
263 |
138 |
$19K |
| D1110 |
Prophylaxis - adult |
391 |
379 |
$17K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,823 |
530 |
$16K |
| D0120 |
Periodic oral evaluation - established patient |
597 |
581 |
$15K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
400 |
328 |
$11K |
| D1351 |
Sealant - per tooth |
364 |
102 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
786 |
738 |
$9K |
| D0330 |
Panoramic radiographic image |
144 |
144 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
118 |
41 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
64 |
37 |
$4K |
| D0274 |
Bitewings - four radiographic images |
106 |
106 |
$3K |
| D0272 |
Bitewings - two radiographic images |
96 |
79 |
$1K |
| D0145 |
Oral evaluation for a patient under three years of age |
12 |
12 |
$298.32 |