| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
954 |
929 |
$35K |
| D0120 |
Periodic oral evaluation - established patient |
1,151 |
1,129 |
$29K |
| D1206 |
Topical application of fluoride varnish |
894 |
863 |
$20K |
| D9248 |
|
63 |
51 |
$14K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
153 |
69 |
$11K |
| D1110 |
Prophylaxis - adult |
232 |
232 |
$11K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
64 |
27 |
$9K |
| D0272 |
Bitewings - two radiographic images |
325 |
316 |
$7K |
| D1310 |
|
422 |
422 |
$6K |
| D0274 |
Bitewings - four radiographic images |
151 |
151 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
271 |
271 |
$5K |
| D1351 |
Sealant - per tooth |
161 |
36 |
$4K |
| D1330 |
|
299 |
299 |
$4K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
63 |
61 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
98 |
92 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
18 |
13 |
$1K |
| D1320 |
|
77 |
77 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
15 |
13 |
$941.20 |
| D0220 |
Intraoral - periapical first radiographic image |
31 |
31 |
$396.35 |