| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
4,798 |
3,802 |
$106K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,157 |
630 |
$105K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,503 |
1,996 |
$91K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
614 |
370 |
$78K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,915 |
1,410 |
$67K |
| D1206 |
Topical application of fluoride varnish |
4,729 |
3,743 |
$62K |
| D0120 |
Periodic oral evaluation - established patient |
2,029 |
1,787 |
$47K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
675 |
335 |
$41K |
| D1351 |
Sealant - per tooth |
1,095 |
315 |
$27K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,065 |
685 |
$21K |
| D0240 |
|
1,773 |
655 |
$21K |
| D7140 |
Extraction, erupted tooth or exposed root |
388 |
225 |
$21K |
| D0272 |
Bitewings - two radiographic images |
1,513 |
1,157 |
$19K |
| D0220 |
Intraoral - periapical first radiographic image |
1,570 |
1,221 |
$19K |
| D0330 |
Panoramic radiographic image |
537 |
344 |
$15K |
| D0140 |
Limited oral evaluation - problem focused |
509 |
354 |
$13K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
36 |
26 |
$4K |
| D1510 |
|
14 |
13 |
$3K |
| D0145 |
Oral evaluation for a patient under three years of age |
326 |
197 |
$1K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
14 |
12 |
$1K |