| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,815 |
2,742 |
$76K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
723 |
387 |
$60K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
504 |
259 |
$56K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,209 |
1,156 |
$54K |
| D0120 |
Periodic oral evaluation - established patient |
1,949 |
1,917 |
$51K |
| D1206 |
Topical application of fluoride varnish |
2,947 |
2,879 |
$48K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
949 |
852 |
$44K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
272 |
83 |
$41K |
| D1351 |
Sealant - per tooth |
1,359 |
319 |
$38K |
| D0220 |
Intraoral - periapical first radiographic image |
1,919 |
1,824 |
$29K |
| D7140 |
Extraction, erupted tooth or exposed root |
429 |
191 |
$28K |
| D0272 |
Bitewings - two radiographic images |
1,378 |
1,339 |
$23K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,719 |
1,605 |
$21K |
| D0330 |
Panoramic radiographic image |
306 |
293 |
$13K |
| D1110 |
Prophylaxis - adult |
91 |
90 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
69 |
66 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
20 |
20 |
$363.20 |