| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
861 |
724 |
$31K |
| D1206 |
Topical application of fluoride varnish |
911 |
779 |
$26K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
435 |
82 |
$17K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
432 |
397 |
$13K |
| D0272 |
Bitewings - two radiographic images |
771 |
673 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
252 |
132 |
$11K |
| D7140 |
Extraction, erupted tooth or exposed root |
369 |
110 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
395 |
332 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,493 |
826 |
$7K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
380 |
335 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
580 |
484 |
$5K |
| D9310 |
|
65 |
56 |
$2K |
| D1351 |
Sealant - per tooth |
91 |
29 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
65 |
26 |
$2K |
| D0330 |
Panoramic radiographic image |
42 |
42 |
$1K |
| D0601 |
|
279 |
278 |
$1K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
44 |
12 |
$960.00 |
| D0602 |
|
53 |
53 |
$225.00 |