| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
809 |
808 |
$47K |
| D0120 |
Periodic oral evaluation - established patient |
729 |
727 |
$20K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
252 |
140 |
$18K |
| D1208 |
Topical application of fluoride, excluding varnish |
961 |
958 |
$18K |
| D0330 |
Panoramic radiographic image |
119 |
119 |
$9K |
| D0272 |
Bitewings - two radiographic images |
342 |
342 |
$8K |
| D1110 |
Prophylaxis - adult |
125 |
124 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
220 |
219 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
80 |
41 |
$6K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
129 |
123 |
$4K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
28 |
12 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
268 |
264 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
39 |
25 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
199 |
126 |
$2K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
25 |
12 |
$2K |
| D0274 |
Bitewings - four radiographic images |
33 |
33 |
$1K |
| D1351 |
Sealant - per tooth |
47 |
14 |
$820.95 |