| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
5,376 |
5,314 |
$137K |
| D1206 |
Topical application of fluoride varnish |
6,284 |
6,204 |
$125K |
| D0120 |
Periodic oral evaluation - established patient |
4,538 |
4,483 |
$101K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
802 |
452 |
$53K |
| D1351 |
Sealant - per tooth |
1,497 |
383 |
$41K |
| D0603 |
|
4,373 |
4,313 |
$40K |
| D0272 |
Bitewings - two radiographic images |
1,805 |
1,782 |
$33K |
| D1110 |
Prophylaxis - adult |
681 |
670 |
$30K |
| D1330 |
|
5,250 |
5,188 |
$25K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
580 |
553 |
$20K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
656 |
644 |
$15K |
| D0145 |
Oral evaluation for a patient under three years of age |
543 |
543 |
$12K |
| D9248 |
|
94 |
91 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
983 |
955 |
$9K |
| D0602 |
|
757 |
757 |
$8K |
| D0330 |
Panoramic radiographic image |
171 |
170 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
665 |
654 |
$6K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
43 |
26 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
61 |
41 |
$3K |
| D0274 |
Bitewings - four radiographic images |
66 |
65 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
27 |
24 |
$2K |
| D9110 |
|
52 |
52 |
$2K |
| D0601 |
|
103 |
103 |
$1K |
| D1310 |
|
3,088 |
3,030 |
$21.00 |