| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,802 |
1,776 |
$81K |
| D0120 |
Periodic oral evaluation - established patient |
2,813 |
2,786 |
$72K |
| D1206 |
Topical application of fluoride varnish |
3,002 |
2,906 |
$56K |
| D1120 |
Prophylaxis - child |
1,268 |
1,209 |
$41K |
| D0272 |
Bitewings - two radiographic images |
1,723 |
1,686 |
$39K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,601 |
1,321 |
$37K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
402 |
206 |
$29K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
155 |
51 |
$21K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
234 |
111 |
$19K |
| D0274 |
Bitewings - four radiographic images |
725 |
724 |
$17K |
| D0330 |
Panoramic radiographic image |
174 |
170 |
$8K |
| D1351 |
Sealant - per tooth |
283 |
81 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
428 |
418 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
82 |
82 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
392 |
335 |
$5K |
| D2140 |
|
74 |
38 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
143 |
134 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
32 |
13 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
22 |
13 |
$335.50 |