| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
4,643 |
2,673 |
$89K |
| D0120 |
Periodic oral evaluation - established patient |
5,936 |
3,410 |
$80K |
| D1206 |
Topical application of fluoride varnish |
5,233 |
3,009 |
$59K |
| D0330 |
Panoramic radiographic image |
1,412 |
817 |
$28K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,374 |
751 |
$22K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
500 |
251 |
$20K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
308 |
147 |
$19K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,414 |
726 |
$19K |
| D1110 |
Prophylaxis - adult |
765 |
454 |
$19K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
423 |
207 |
$14K |
| D0272 |
Bitewings - two radiographic images |
1,358 |
760 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
1,870 |
1,080 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
651 |
403 |
$11K |
| D0274 |
Bitewings - four radiographic images |
513 |
309 |
$8K |
| D1354 |
|
1,895 |
324 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
466 |
276 |
$6K |
| D1351 |
Sealant - per tooth |
291 |
66 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
190 |
78 |
$3K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
34 |
12 |
$994.44 |