| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,402 |
1,397 |
$48K |
| D0120 |
Periodic oral evaluation - established patient |
1,325 |
1,319 |
$39K |
| D1206 |
Topical application of fluoride varnish |
1,403 |
1,398 |
$37K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
400 |
241 |
$34K |
| D0272 |
Bitewings - two radiographic images |
1,048 |
1,044 |
$18K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
308 |
287 |
$17K |
| D0330 |
Panoramic radiographic image |
189 |
188 |
$15K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
143 |
100 |
$12K |
| D1351 |
Sealant - per tooth |
365 |
109 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
230 |
229 |
$11K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
59 |
29 |
$9K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
69 |
41 |
$7K |
| D1110 |
Prophylaxis - adult |
116 |
115 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
96 |
95 |
$4K |
| D0274 |
Bitewings - four radiographic images |
66 |
66 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
210 |
204 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
16 |
16 |
$471.68 |
| D0230 |
Intraoral - periapical each additional radiographic image |
54 |
53 |
$458.57 |