| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,592 |
1,592 |
$59K |
| D1206 |
Topical application of fluoride varnish |
2,151 |
2,148 |
$48K |
| D1351 |
Sealant - per tooth |
1,531 |
388 |
$48K |
| D0120 |
Periodic oral evaluation - established patient |
1,801 |
1,798 |
$45K |
| D7140 |
Extraction, erupted tooth or exposed root |
457 |
269 |
$37K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
664 |
649 |
$36K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
260 |
154 |
$32K |
| D0272 |
Bitewings - two radiographic images |
1,206 |
1,204 |
$24K |
| D1110 |
Prophylaxis - adult |
523 |
523 |
$23K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
288 |
210 |
$22K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
318 |
238 |
$20K |
| D0603 |
|
1,420 |
1,420 |
$14K |
| D0240 |
|
667 |
527 |
$14K |
| D9248 |
|
59 |
59 |
$14K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
183 |
99 |
$13K |
| D0274 |
Bitewings - four radiographic images |
297 |
297 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
344 |
344 |
$9K |
| D1330 |
|
1,547 |
1,546 |
$8K |
| D0330 |
Panoramic radiographic image |
160 |
160 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
80 |
80 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
387 |
385 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
214 |
204 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
96 |
96 |
$1K |
| D0145 |
Oral evaluation for a patient under three years of age |
57 |
57 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
39 |
38 |
$818.77 |
| D0602 |
|
40 |
40 |
$400.00 |