| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
656 |
615 |
$27K |
| D1206 |
Topical application of fluoride varnish |
653 |
611 |
$20K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
291 |
109 |
$12K |
| D0274 |
Bitewings - four radiographic images |
480 |
392 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
296 |
276 |
$8K |
| D1351 |
Sealant - per tooth |
258 |
52 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
756 |
643 |
$5K |
| D0350 |
|
768 |
635 |
$5K |
| D0330 |
Panoramic radiographic image |
128 |
117 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
295 |
271 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
710 |
600 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
84 |
30 |
$3K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
149 |
13 |
$3K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
152 |
13 |
$2K |
| D0603 |
|
515 |
434 |
$2K |
| D0272 |
Bitewings - two radiographic images |
92 |
80 |
$1K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
153 |
14 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
94 |
79 |
$1K |
| D2140 |
|
95 |
12 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
82 |
33 |
$1K |
| D7111 |
|
116 |
12 |
$651.00 |
| D0602 |
|
177 |
169 |
$625.00 |
| D9420 |
|
66 |
16 |
$614.85 |
| D0145 |
Oral evaluation for a patient under three years of age |
18 |
15 |
$307.50 |
| D0240 |
|
67 |
16 |
$212.10 |