| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
777 |
777 |
$33K |
| D0120 |
Periodic oral evaluation - established patient |
992 |
992 |
$27K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
258 |
154 |
$19K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
222 |
217 |
$16K |
| D1351 |
Sealant - per tooth |
351 |
106 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
349 |
349 |
$10K |
| D1110 |
Prophylaxis - adult |
167 |
167 |
$9K |
| D2161 |
|
58 |
51 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
490 |
490 |
$7K |
| D1206 |
Topical application of fluoride varnish |
247 |
247 |
$7K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
56 |
34 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
167 |
167 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
98 |
69 |
$5K |
| D0330 |
Panoramic radiographic image |
100 |
100 |
$5K |
| D2394 |
|
36 |
30 |
$4K |
| D2160 |
|
42 |
35 |
$4K |
| D0272 |
Bitewings - two radiographic images |
201 |
201 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
282 |
281 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
83 |
52 |
$4K |
| D0274 |
Bitewings - four radiographic images |
78 |
78 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
125 |
122 |
$2K |