| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,328 |
1,315 |
$75K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
291 |
126 |
$34K |
| D0120 |
Periodic oral evaluation - established patient |
1,264 |
1,251 |
$32K |
| D0330 |
Panoramic radiographic image |
408 |
407 |
$27K |
| D1206 |
Topical application of fluoride varnish |
1,484 |
1,471 |
$26K |
| D7140 |
Extraction, erupted tooth or exposed root |
248 |
141 |
$19K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
276 |
187 |
$18K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,026 |
696 |
$18K |
| D0272 |
Bitewings - two radiographic images |
643 |
638 |
$14K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
322 |
309 |
$11K |
| D1351 |
Sealant - per tooth |
484 |
155 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
868 |
842 |
$10K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
131 |
68 |
$9K |
| D1110 |
Prophylaxis - adult |
124 |
124 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
217 |
217 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
138 |
132 |
$5K |
| D0274 |
Bitewings - four radiographic images |
44 |
44 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
12 |
12 |
$686.40 |