| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
4,404 |
4,399 |
$113K |
| D0120 |
Periodic oral evaluation - established patient |
4,033 |
4,033 |
$88K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
520 |
220 |
$59K |
| D1206 |
Topical application of fluoride varnish |
2,178 |
2,123 |
$53K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,643 |
2,470 |
$50K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
616 |
394 |
$46K |
| D0272 |
Bitewings - two radiographic images |
3,210 |
3,206 |
$40K |
| D1351 |
Sealant - per tooth |
1,569 |
324 |
$39K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
443 |
278 |
$38K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
425 |
188 |
$29K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
933 |
928 |
$26K |
| D1999 |
|
1,233 |
1,213 |
$12K |
| D0274 |
Bitewings - four radiographic images |
378 |
378 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
228 |
224 |
$5K |
| D0330 |
Panoramic radiographic image |
193 |
193 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
695 |
690 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
59 |
59 |
$3K |
| D1110 |
Prophylaxis - adult |
69 |
69 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
385 |
380 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
31 |
31 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
18 |
12 |
$936.00 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$242.00 |