| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,736 |
1,705 |
$40K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
325 |
113 |
$25K |
| D1206 |
Topical application of fluoride varnish |
1,715 |
1,678 |
$24K |
| D0120 |
Periodic oral evaluation - established patient |
1,406 |
1,380 |
$22K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
310 |
287 |
$11K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
69 |
16 |
$8K |
| D0272 |
Bitewings - two radiographic images |
432 |
425 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
492 |
475 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
473 |
180 |
$4K |
| D1351 |
Sealant - per tooth |
117 |
37 |
$2K |
| D9420 |
|
15 |
15 |
$2K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
30 |
14 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
59 |
58 |
$1K |
| D0330 |
Panoramic radiographic image |
16 |
16 |
$566.30 |