| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,990 |
1,969 |
$110K |
| D0120 |
Periodic oral evaluation - established patient |
1,363 |
1,357 |
$37K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
500 |
186 |
$34K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
258 |
78 |
$31K |
| D1206 |
Topical application of fluoride varnish |
1,648 |
1,632 |
$30K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
965 |
952 |
$26K |
| D0272 |
Bitewings - two radiographic images |
1,275 |
1,270 |
$26K |
| D0330 |
Panoramic radiographic image |
361 |
360 |
$23K |
| D7140 |
Extraction, erupted tooth or exposed root |
213 |
82 |
$16K |
| D1110 |
Prophylaxis - adult |
217 |
217 |
$13K |
| D1351 |
Sealant - per tooth |
472 |
114 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
165 |
77 |
$9K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
128 |
48 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
186 |
184 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
697 |
678 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
546 |
544 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
517 |
456 |
$5K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
101 |
96 |
$3K |
| D2330 |
|
28 |
13 |
$2K |
| D0274 |
Bitewings - four radiographic images |
30 |
30 |
$1K |