| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,944 |
1,936 |
$83K |
| D1206 |
Topical application of fluoride varnish |
1,845 |
1,839 |
$47K |
| D1351 |
Sealant - per tooth |
1,511 |
345 |
$47K |
| D0120 |
Periodic oral evaluation - established patient |
1,676 |
1,673 |
$45K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
558 |
546 |
$29K |
| D7140 |
Extraction, erupted tooth or exposed root |
316 |
184 |
$25K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
189 |
94 |
$23K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
278 |
200 |
$20K |
| D1110 |
Prophylaxis - adult |
425 |
423 |
$18K |
| D0272 |
Bitewings - two radiographic images |
963 |
962 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
419 |
419 |
$12K |
| D0603 |
|
1,340 |
1,336 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
182 |
150 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
483 |
481 |
$11K |
| D0274 |
Bitewings - four radiographic images |
317 |
316 |
$10K |
| D0240 |
|
377 |
329 |
$8K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
106 |
69 |
$7K |
| D0330 |
Panoramic radiographic image |
157 |
156 |
$7K |
| D1330 |
|
1,113 |
1,110 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
288 |
287 |
$3K |
| D0602 |
|
232 |
232 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
88 |
87 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
126 |
121 |
$1K |
| D9995 |
|
21 |
21 |
$105.00 |