| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,002 |
964 |
$39K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
344 |
190 |
$38K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
806 |
770 |
$29K |
| D1206 |
Topical application of fluoride varnish |
1,125 |
1,085 |
$24K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
463 |
355 |
$18K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
145 |
92 |
$14K |
| D0272 |
Bitewings - two radiographic images |
514 |
495 |
$13K |
| D0330 |
Panoramic radiographic image |
205 |
200 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
707 |
672 |
$11K |
| D1354 |
|
203 |
92 |
$10K |
| D1351 |
Sealant - per tooth |
359 |
73 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,324 |
588 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
354 |
349 |
$10K |
| D7140 |
Extraction, erupted tooth or exposed root |
100 |
53 |
$8K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
60 |
16 |
$6K |
| D1110 |
Prophylaxis - adult |
82 |
82 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
65 |
64 |
$2K |
| D0274 |
Bitewings - four radiographic images |
60 |
60 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
16 |
12 |
$2K |
| D9310 |
|
13 |
12 |
$660.00 |