| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,511 |
1,335 |
$58K |
| D1351 |
Sealant - per tooth |
2,689 |
474 |
$51K |
| D1206 |
Topical application of fluoride varnish |
1,491 |
1,322 |
$44K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
625 |
235 |
$24K |
| D0274 |
Bitewings - four radiographic images |
1,035 |
846 |
$17K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
643 |
526 |
$15K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
374 |
180 |
$12K |
| D0350 |
|
2,099 |
1,368 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
717 |
668 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
1,695 |
1,401 |
$10K |
| D0330 |
Panoramic radiographic image |
262 |
241 |
$9K |
| D7111 |
|
498 |
172 |
$9K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
150 |
57 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,606 |
1,321 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
293 |
235 |
$7K |
| D0272 |
Bitewings - two radiographic images |
328 |
276 |
$5K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
108 |
44 |
$4K |
| D9420 |
|
120 |
107 |
$4K |
| D0603 |
|
1,198 |
1,048 |
$4K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
220 |
184 |
$3K |
| D0145 |
Oral evaluation for a patient under three years of age |
133 |
118 |
$2K |
| D0602 |
|
385 |
327 |
$1K |
| D0240 |
|
109 |
100 |
$1K |
| D1353 |
|
70 |
27 |
$1K |
| D2330 |
|
20 |
12 |
$958.46 |