| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,838 |
2,830 |
$95K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
765 |
398 |
$84K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,201 |
749 |
$69K |
| D1206 |
Topical application of fluoride varnish |
3,332 |
3,321 |
$69K |
| D0120 |
Periodic oral evaluation - established patient |
2,655 |
2,644 |
$63K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
863 |
572 |
$62K |
| D9248 |
|
558 |
517 |
$46K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,321 |
1,195 |
$38K |
| D1110 |
Prophylaxis - adult |
725 |
720 |
$30K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
995 |
994 |
$29K |
| D0272 |
Bitewings - two radiographic images |
1,313 |
1,310 |
$22K |
| D0330 |
Panoramic radiographic image |
654 |
654 |
$20K |
| D0274 |
Bitewings - four radiographic images |
707 |
702 |
$18K |
| D7140 |
Extraction, erupted tooth or exposed root |
112 |
69 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
198 |
196 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
331 |
316 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
162 |
63 |
$1K |