| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,033 |
3,017 |
$100K |
| D0120 |
Periodic oral evaluation - established patient |
3,642 |
3,623 |
$85K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,387 |
2,371 |
$47K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
717 |
428 |
$42K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
375 |
198 |
$40K |
| D1110 |
Prophylaxis - adult |
886 |
882 |
$37K |
| D1206 |
Topical application of fluoride varnish |
1,492 |
1,488 |
$30K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
914 |
888 |
$26K |
| D0272 |
Bitewings - two radiographic images |
1,486 |
1,476 |
$26K |
| D0330 |
Panoramic radiographic image |
527 |
522 |
$24K |
| D1351 |
Sealant - per tooth |
698 |
238 |
$19K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
254 |
156 |
$18K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
244 |
123 |
$18K |
| D0274 |
Bitewings - four radiographic images |
448 |
446 |
$12K |
| D7140 |
Extraction, erupted tooth or exposed root |
183 |
99 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
697 |
687 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
259 |
259 |
$7K |
| D9248 |
|
57 |
57 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
199 |
195 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
379 |
349 |
$3K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
37 |
28 |
$3K |