| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
5,592 |
4,274 |
$95K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,816 |
2,484 |
$78K |
| D1206 |
Topical application of fluoride varnish |
4,445 |
3,792 |
$75K |
| D0120 |
Periodic oral evaluation - established patient |
2,679 |
1,733 |
$35K |
| D0272 |
Bitewings - two radiographic images |
2,729 |
2,174 |
$32K |
| D0330 |
Panoramic radiographic image |
778 |
672 |
$28K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
362 |
80 |
$27K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
366 |
175 |
$26K |
| D1351 |
Sealant - per tooth |
1,397 |
270 |
$24K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
796 |
666 |
$19K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
341 |
166 |
$18K |
| D0140 |
Limited oral evaluation - problem focused |
212 |
174 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
110 |
52 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,098 |
488 |
$4K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
132 |
32 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
354 |
294 |
$3K |