| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,516 |
1,499 |
$50K |
| D0330 |
Panoramic radiographic image |
660 |
654 |
$36K |
| D1110 |
Prophylaxis - adult |
749 |
746 |
$34K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
513 |
247 |
$33K |
| D0120 |
Periodic oral evaluation - established patient |
1,231 |
1,222 |
$32K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
750 |
732 |
$32K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
891 |
776 |
$22K |
| D0272 |
Bitewings - two radiographic images |
1,086 |
1,080 |
$21K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
169 |
78 |
$21K |
| D1208 |
Topical application of fluoride, excluding varnish |
959 |
954 |
$18K |
| D1206 |
Topical application of fluoride varnish |
682 |
676 |
$16K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
176 |
124 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
792 |
764 |
$10K |
| D9920 |
|
200 |
150 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
350 |
341 |
$5K |
| D0145 |
Oral evaluation for a patient under three years of age |
69 |
69 |
$3K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
29 |
14 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
36 |
18 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
103 |
69 |
$943.92 |
| D1351 |
Sealant - per tooth |
43 |
12 |
$808.77 |