| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,724 |
1,668 |
$44K |
| D1206 |
Topical application of fluoride varnish |
1,884 |
1,821 |
$30K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
205 |
55 |
$24K |
| D0120 |
Periodic oral evaluation - established patient |
1,028 |
1,004 |
$21K |
| D0272 |
Bitewings - two radiographic images |
647 |
620 |
$13K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
214 |
49 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
140 |
53 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
333 |
325 |
$10K |
| D0240 |
|
529 |
275 |
$9K |
| D7140 |
Extraction, erupted tooth or exposed root |
92 |
40 |
$8K |
| D9420 |
|
85 |
85 |
$5K |
| D1351 |
Sealant - per tooth |
137 |
29 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
89 |
86 |
$2K |
| D0330 |
Panoramic radiographic image |
65 |
62 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
15 |
15 |
$440.25 |