| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,514 |
3,441 |
$137K |
| D0120 |
Periodic oral evaluation - established patient |
3,235 |
3,176 |
$98K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
980 |
554 |
$72K |
| D0274 |
Bitewings - four radiographic images |
1,552 |
1,522 |
$57K |
| D1206 |
Topical application of fluoride varnish |
3,537 |
3,466 |
$56K |
| D0210 |
Intraoral - complete series of radiographic images |
511 |
508 |
$38K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
562 |
365 |
$37K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,234 |
1,108 |
$28K |
| D1351 |
Sealant - per tooth |
774 |
355 |
$26K |
| D0272 |
Bitewings - two radiographic images |
1,103 |
1,078 |
$26K |
| D0220 |
Intraoral - periapical first radiographic image |
841 |
805 |
$14K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
104 |
59 |
$14K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
43 |
27 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
90 |
86 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
61 |
39 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
154 |
107 |
$1K |