| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
382 |
382 |
$25K |
| D0120 |
Periodic oral evaluation - established patient |
203 |
203 |
$20K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
76 |
50 |
$16K |
| D1206 |
Topical application of fluoride varnish |
386 |
385 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
144 |
144 |
$12K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
40 |
16 |
$10K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
116 |
106 |
$10K |
| D0272 |
Bitewings - two radiographic images |
167 |
167 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
45 |
32 |
$7K |
| D1354 |
|
281 |
63 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
197 |
192 |
$5K |
| D0145 |
Oral evaluation for a patient under three years of age |
64 |
64 |
$5K |
| D0240 |
|
111 |
59 |
$4K |
| D1351 |
Sealant - per tooth |
72 |
33 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
185 |
161 |
$4K |
| D0603 |
|
277 |
277 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
20 |
15 |
$3K |
| D1110 |
Prophylaxis - adult |
22 |
22 |
$3K |
| D0274 |
Bitewings - four radiographic images |
39 |
39 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
14 |
14 |
$1K |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$1K |