| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
4,815 |
4,804 |
$153K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
1,219 |
633 |
$126K |
| D0120 |
Periodic oral evaluation - established patient |
5,306 |
5,297 |
$122K |
| D1110 |
Prophylaxis - adult |
1,596 |
1,594 |
$68K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,175 |
1,894 |
$67K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
443 |
297 |
$54K |
| D1351 |
Sealant - per tooth |
1,584 |
517 |
$53K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,057 |
4,048 |
$52K |
| D0272 |
Bitewings - two radiographic images |
2,344 |
2,341 |
$48K |
| D1206 |
Topical application of fluoride varnish |
2,135 |
2,130 |
$38K |
| D0274 |
Bitewings - four radiographic images |
871 |
870 |
$26K |
| D0330 |
Panoramic radiographic image |
364 |
363 |
$19K |
| D0220 |
Intraoral - periapical first radiographic image |
1,331 |
1,321 |
$17K |
| D0145 |
Oral evaluation for a patient under three years of age |
533 |
530 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
343 |
343 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,010 |
1,008 |
$13K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
95 |
65 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
69 |
41 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
80 |
80 |
$3K |
| D7111 |
|
42 |
26 |
$2K |
| D2140 |
|
16 |
14 |
$1K |