| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,973 |
2,947 |
$30K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
733 |
555 |
$22K |
| D1206 |
Topical application of fluoride varnish |
3,497 |
3,459 |
$21K |
| D0120 |
Periodic oral evaluation - established patient |
2,685 |
2,653 |
$16K |
| D9920 |
|
531 |
524 |
$15K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,374 |
1,319 |
$15K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
559 |
416 |
$12K |
| D1351 |
Sealant - per tooth |
879 |
333 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
716 |
710 |
$9K |
| D1110 |
Prophylaxis - adult |
640 |
628 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,019 |
750 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
473 |
287 |
$6K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
467 |
235 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
138 |
124 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
1,170 |
1,145 |
$4K |
| D0272 |
Bitewings - two radiographic images |
774 |
766 |
$4K |
| D0274 |
Bitewings - four radiographic images |
467 |
460 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
440 |
432 |
$3K |
| D0240 |
|
769 |
448 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
171 |
171 |
$0.00 |
| D0330 |
Panoramic radiographic image |
136 |
136 |
$0.00 |
| D3120 |
|
47 |
40 |
$0.00 |