| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,911 |
2,807 |
$93K |
| D1206 |
Topical application of fluoride varnish |
5,016 |
4,448 |
$82K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
611 |
362 |
$76K |
| D0120 |
Periodic oral evaluation - established patient |
2,394 |
2,333 |
$57K |
| D0330 |
Panoramic radiographic image |
804 |
790 |
$46K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
672 |
571 |
$36K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
245 |
55 |
$35K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
949 |
912 |
$35K |
| D0140 |
Limited oral evaluation - problem focused |
723 |
694 |
$28K |
| D7140 |
Extraction, erupted tooth or exposed root |
226 |
78 |
$20K |
| D0145 |
Oral evaluation for a patient under three years of age |
497 |
484 |
$18K |
| D0272 |
Bitewings - two radiographic images |
799 |
768 |
$18K |
| D1110 |
Prophylaxis - adult |
325 |
317 |
$15K |
| D1351 |
Sealant - per tooth |
552 |
138 |
$14K |
| D0240 |
|
627 |
420 |
$13K |
| D1330 |
|
424 |
422 |
$9K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
81 |
37 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
211 |
199 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
41 |
24 |
$3K |
| D9420 |
|
12 |
12 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
72 |
27 |
$490.00 |