| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
641 |
641 |
$26K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
344 |
338 |
$25K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
289 |
151 |
$22K |
| D0120 |
Periodic oral evaluation - established patient |
699 |
699 |
$19K |
| D1351 |
Sealant - per tooth |
403 |
144 |
$15K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
137 |
67 |
$15K |
| D1206 |
Topical application of fluoride varnish |
319 |
319 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
252 |
252 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
146 |
75 |
$7K |
| D0272 |
Bitewings - two radiographic images |
322 |
322 |
$7K |
| D1110 |
Prophylaxis - adult |
117 |
117 |
$6K |
| D0330 |
Panoramic radiographic image |
124 |
124 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
428 |
428 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
418 |
418 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
117 |
75 |
$6K |
| D0274 |
Bitewings - four radiographic images |
137 |
137 |
$5K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
55 |
28 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
116 |
116 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$184.30 |