| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
4,975 |
4,892 |
$217K |
| D0120 |
Periodic oral evaluation - established patient |
3,465 |
3,402 |
$115K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,480 |
1,465 |
$92K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
629 |
386 |
$64K |
| D1206 |
Topical application of fluoride varnish |
2,158 |
2,123 |
$59K |
| D0140 |
Limited oral evaluation - problem focused |
860 |
831 |
$39K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
483 |
468 |
$27K |
| D0272 |
Bitewings - two radiographic images |
283 |
280 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
178 |
175 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
42 |
29 |
$3K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
13 |
12 |
$3K |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$1K |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$564.48 |