| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,761 |
3,751 |
$117K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
793 |
208 |
$91K |
| D0120 |
Periodic oral evaluation - established patient |
3,224 |
3,214 |
$72K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,845 |
3,835 |
$69K |
| D0272 |
Bitewings - two radiographic images |
1,891 |
1,886 |
$37K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,223 |
1,186 |
$33K |
| D0220 |
Intraoral - periapical first radiographic image |
2,432 |
2,419 |
$27K |
| D1351 |
Sealant - per tooth |
1,075 |
294 |
$25K |
| D0274 |
Bitewings - four radiographic images |
812 |
810 |
$23K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,363 |
2,192 |
$22K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
460 |
460 |
$16K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
155 |
113 |
$11K |
| D0330 |
Panoramic radiographic image |
279 |
279 |
$10K |
| D2932 |
|
77 |
24 |
$9K |
| D7140 |
Extraction, erupted tooth or exposed root |
123 |
60 |
$8K |
| D9420 |
|
89 |
88 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
120 |
74 |
$6K |
| D0240 |
|
416 |
279 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
105 |
104 |
$3K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
35 |
12 |
$3K |
| D2140 |
|
36 |
28 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
27 |
27 |
$2K |