| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
1,670 |
1,613 |
$45K |
| D0120 |
Periodic oral evaluation - established patient |
1,578 |
1,525 |
$45K |
| D1120 |
Prophylaxis - child |
1,135 |
1,099 |
$40K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
399 |
332 |
$33K |
| D1110 |
Prophylaxis - adult |
519 |
503 |
$31K |
| D0330 |
Panoramic radiographic image |
377 |
365 |
$30K |
| D1351 |
Sealant - per tooth |
976 |
350 |
$28K |
| D0272 |
Bitewings - two radiographic images |
818 |
800 |
$20K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
99 |
55 |
$18K |
| D0274 |
Bitewings - four radiographic images |
456 |
448 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
193 |
153 |
$14K |
| D2140 |
|
161 |
122 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
393 |
262 |
$8K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
79 |
63 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
325 |
316 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
172 |
147 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
62 |
60 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
54 |
53 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
18 |
13 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
34 |
30 |
$769.00 |
| D0240 |
|
16 |
13 |
$269.00 |