| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,605 |
2,605 |
$91K |
| D1351 |
Sealant - per tooth |
2,502 |
1,009 |
$75K |
| D1110 |
Prophylaxis - adult |
1,364 |
1,364 |
$69K |
| D1206 |
Topical application of fluoride varnish |
3,936 |
3,936 |
$64K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
604 |
420 |
$62K |
| D0120 |
Periodic oral evaluation - established patient |
2,531 |
2,531 |
$58K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,160 |
1,160 |
$47K |
| D0330 |
Panoramic radiographic image |
893 |
893 |
$45K |
| D0274 |
Bitewings - four radiographic images |
1,588 |
1,588 |
$44K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,186 |
1,117 |
$39K |
| D0272 |
Bitewings - two radiographic images |
1,650 |
1,650 |
$31K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
396 |
315 |
$31K |
| D7140 |
Extraction, erupted tooth or exposed root |
313 |
224 |
$28K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
174 |
106 |
$22K |
| D0240 |
|
725 |
383 |
$13K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
96 |
84 |
$12K |
| D0145 |
Oral evaluation for a patient under three years of age |
315 |
315 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
884 |
863 |
$11K |
| D0140 |
Limited oral evaluation - problem focused |
193 |
191 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
392 |
321 |
$4K |