| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,996 |
1,793 |
$17K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
408 |
138 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
2,129 |
1,908 |
$12K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,138 |
1,976 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
580 |
258 |
$6K |
| D1110 |
Prophylaxis - adult |
527 |
478 |
$5K |
| D1206 |
Topical application of fluoride varnish |
328 |
231 |
$4K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
196 |
82 |
$4K |
| D0272 |
Bitewings - two radiographic images |
818 |
729 |
$4K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
587 |
497 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
389 |
365 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
355 |
330 |
$2K |
| D0330 |
Panoramic radiographic image |
83 |
74 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
221 |
118 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
225 |
103 |
$1K |
| D0240 |
|
250 |
227 |
$851.00 |
| D0274 |
Bitewings - four radiographic images |
86 |
83 |
$500.55 |
| D9248 |
|
35 |
32 |
$77.00 |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$53.00 |
| D1351 |
Sealant - per tooth |
133 |
27 |
$0.00 |