| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,430 |
1,420 |
$49K |
| D0120 |
Periodic oral evaluation - established patient |
1,364 |
1,356 |
$34K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
297 |
189 |
$29K |
| D1206 |
Topical application of fluoride varnish |
1,429 |
1,419 |
$29K |
| D0272 |
Bitewings - two radiographic images |
967 |
960 |
$20K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
347 |
336 |
$8K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
25 |
14 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
45 |
28 |
$4K |
| D0330 |
Panoramic radiographic image |
65 |
65 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
207 |
198 |
$3K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
25 |
12 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
33 |
33 |
$2K |
| D0240 |
|
164 |
132 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
29 |
29 |
$1K |
| D0274 |
Bitewings - four radiographic images |
36 |
36 |
$1K |
| D1351 |
Sealant - per tooth |
33 |
15 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
28 |
27 |
$982.66 |