| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
6,299 |
6,285 |
$284K |
| D1206 |
Topical application of fluoride varnish |
6,193 |
6,180 |
$187K |
| D0272 |
Bitewings - two radiographic images |
2,743 |
2,733 |
$74K |
| D0120 |
Periodic oral evaluation - established patient |
1,804 |
1,803 |
$70K |
| D0220 |
Intraoral - periapical first radiographic image |
2,679 |
2,647 |
$53K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
260 |
78 |
$53K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,813 |
2,062 |
$53K |
| D1351 |
Sealant - per tooth |
953 |
213 |
$34K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
340 |
336 |
$21K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
36 |
12 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
27 |
12 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
20 |
14 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
36 |
36 |
$2K |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$696.00 |
| D0274 |
Bitewings - four radiographic images |
14 |
14 |
$616.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
55 |
54 |
$0.00 |