| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
747 |
632 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
510 |
456 |
$10K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
97 |
15 |
$9K |
| D1206 |
Topical application of fluoride varnish |
590 |
493 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
285 |
230 |
$6K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
198 |
156 |
$4K |
| D0272 |
Bitewings - two radiographic images |
262 |
215 |
$3K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
40 |
12 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
70 |
67 |
$1K |
| D0330 |
Panoramic radiographic image |
62 |
43 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
39 |
12 |
$700.00 |
| D0274 |
Bitewings - four radiographic images |
18 |
14 |
$467.07 |
| D0220 |
Intraoral - periapical first radiographic image |
35 |
26 |
$375.82 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
24 |
12 |
$357.00 |