| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,862 |
1,850 |
$53K |
| D1206 |
Topical application of fluoride varnish |
2,251 |
2,238 |
$43K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
740 |
479 |
$42K |
| D0120 |
Periodic oral evaluation - established patient |
1,792 |
1,779 |
$37K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
367 |
272 |
$34K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
898 |
821 |
$31K |
| D0272 |
Bitewings - two radiographic images |
929 |
924 |
$16K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
257 |
189 |
$12K |
| D1110 |
Prophylaxis - adult |
268 |
266 |
$11K |
| D1330 |
|
1,384 |
1,380 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
477 |
476 |
$9K |
| D7140 |
Extraction, erupted tooth or exposed root |
157 |
122 |
$9K |
| D0274 |
Bitewings - four radiographic images |
241 |
240 |
$7K |
| D1310 |
|
565 |
560 |
$6K |
| D1351 |
Sealant - per tooth |
196 |
86 |
$5K |
| D0330 |
Panoramic radiographic image |
111 |
111 |
$4K |
| D0601 |
|
174 |
173 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
205 |
203 |
$2K |
| D0603 |
|
155 |
155 |
$1K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
20 |
18 |
$1K |
| D8670 |
Periodic orthodontic treatment visit |
12 |
12 |
$922.10 |
| D1208 |
Topical application of fluoride, excluding varnish |
26 |
26 |
$438.74 |
| D0230 |
Intraoral - periapical each additional radiographic image |
54 |
53 |
$429.13 |
| D1999 |
|
55 |
55 |
$0.00 |