| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
441 |
293 |
$40K |
| D1120 |
Prophylaxis - child |
1,143 |
1,143 |
$34K |
| D0120 |
Periodic oral evaluation - established patient |
1,326 |
1,326 |
$28K |
| D1110 |
Prophylaxis - adult |
618 |
618 |
$28K |
| D0220 |
Intraoral - periapical first radiographic image |
1,307 |
1,290 |
$20K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
689 |
623 |
$18K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
125 |
41 |
$15K |
| D1206 |
Topical application of fluoride varnish |
995 |
995 |
$15K |
| D0140 |
Limited oral evaluation - problem focused |
481 |
470 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
363 |
363 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
723 |
723 |
$11K |
| D0330 |
Panoramic radiographic image |
210 |
210 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,345 |
968 |
$10K |
| D0272 |
Bitewings - two radiographic images |
497 |
497 |
$9K |
| D0274 |
Bitewings - four radiographic images |
267 |
267 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
107 |
52 |
$7K |
| D1351 |
Sealant - per tooth |
235 |
67 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
70 |
51 |
$4K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
14 |
12 |
$2K |