| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,502 |
2,499 |
$96K |
| D0120 |
Periodic oral evaluation - established patient |
2,582 |
2,580 |
$65K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
726 |
710 |
$55K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
498 |
279 |
$38K |
| D1206 |
Topical application of fluoride varnish |
1,245 |
1,244 |
$34K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
227 |
109 |
$24K |
| D1351 |
Sealant - per tooth |
643 |
225 |
$23K |
| D0230 |
Intraoral - periapical each additional radiographic image |
847 |
831 |
$20K |
| D0272 |
Bitewings - two radiographic images |
1,024 |
1,023 |
$19K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,363 |
1,362 |
$18K |
| D1110 |
Prophylaxis - adult |
246 |
246 |
$13K |
| D0330 |
Panoramic radiographic image |
257 |
257 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
927 |
921 |
$11K |
| D0274 |
Bitewings - four radiographic images |
278 |
278 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
250 |
249 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
122 |
66 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
107 |
66 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
41 |
41 |
$678.22 |
| D0145 |
Oral evaluation for a patient under three years of age |
17 |
17 |
$484.50 |