| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,730 |
3,683 |
$163K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,635 |
3,590 |
$99K |
| D0120 |
Periodic oral evaluation - established patient |
2,826 |
2,794 |
$93K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
592 |
358 |
$63K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
752 |
650 |
$43K |
| D1351 |
Sealant - per tooth |
649 |
240 |
$24K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
235 |
152 |
$20K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
322 |
314 |
$19K |
| D0330 |
Panoramic radiographic image |
142 |
139 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
576 |
566 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
224 |
220 |
$10K |
| D0272 |
Bitewings - two radiographic images |
281 |
278 |
$8K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
30 |
24 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
385 |
374 |
$6K |
| D0274 |
Bitewings - four radiographic images |
79 |
78 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
21 |
13 |
$2K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
14 |
12 |
$2K |
| D1206 |
Topical application of fluoride varnish |
31 |
31 |
$881.02 |