| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,692 |
1,623 |
$92K |
| D1206 |
Topical application of fluoride varnish |
1,666 |
1,599 |
$84K |
| D1351 |
Sealant - per tooth |
2,303 |
772 |
$44K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
433 |
216 |
$35K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,006 |
984 |
$32K |
| D0272 |
Bitewings - two radiographic images |
937 |
896 |
$19K |
| D0120 |
Periodic oral evaluation - established patient |
675 |
629 |
$18K |
| D0330 |
Panoramic radiographic image |
397 |
359 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
718 |
684 |
$12K |
| D0274 |
Bitewings - four radiographic images |
525 |
503 |
$12K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
470 |
425 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,388 |
836 |
$8K |
| D0240 |
|
467 |
280 |
$6K |
| D1353 |
|
351 |
186 |
$5K |
| D2140 |
|
89 |
60 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
98 |
56 |
$4K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
39 |
24 |
$2K |
| D0350 |
|
216 |
176 |
$2K |