| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,847 |
2,631 |
$72K |
| D0120 |
Periodic oral evaluation - established patient |
2,696 |
2,483 |
$65K |
| D1351 |
Sealant - per tooth |
1,880 |
485 |
$51K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
498 |
292 |
$48K |
| D1206 |
Topical application of fluoride varnish |
3,009 |
2,789 |
$45K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,079 |
945 |
$44K |
| D0140 |
Limited oral evaluation - problem focused |
870 |
682 |
$30K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,535 |
1,154 |
$28K |
| D0220 |
Intraoral - periapical first radiographic image |
1,591 |
1,469 |
$22K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
473 |
446 |
$20K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
232 |
163 |
$19K |
| D0272 |
Bitewings - two radiographic images |
879 |
824 |
$15K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
117 |
52 |
$14K |
| D0240 |
|
875 |
450 |
$14K |
| D9110 |
|
319 |
241 |
$13K |
| D1110 |
Prophylaxis - adult |
314 |
290 |
$11K |
| D7140 |
Extraction, erupted tooth or exposed root |
152 |
92 |
$9K |
| D1354 |
|
431 |
214 |
$2K |
| D0330 |
Panoramic radiographic image |
40 |
40 |
$2K |
| D7962 |
|
17 |
13 |
$2K |
| D0274 |
Bitewings - four radiographic images |
25 |
24 |
$771.65 |