| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
6,258 |
6,208 |
$107K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,100 |
1,173 |
$59K |
| D1208 |
Topical application of fluoride, excluding varnish |
6,060 |
6,014 |
$56K |
| D0120 |
Periodic oral evaluation - established patient |
5,275 |
5,243 |
$46K |
| D1351 |
Sealant - per tooth |
4,017 |
1,205 |
$38K |
| D0330 |
Panoramic radiographic image |
1,579 |
1,566 |
$26K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
704 |
446 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,306 |
1,299 |
$12K |
| D0272 |
Bitewings - two radiographic images |
2,423 |
2,400 |
$9K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
278 |
168 |
$8K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
838 |
765 |
$7K |
| D1354 |
|
1,099 |
374 |
$5K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
41 |
26 |
$1K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
30 |
27 |
$935.00 |
| D0145 |
Oral evaluation for a patient under three years of age |
106 |
105 |
$913.75 |
| D0240 |
|
136 |
132 |
$430.00 |
| D0220 |
Intraoral - periapical first radiographic image |
25 |
24 |
$60.00 |