| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,597 |
2,591 |
$98K |
| D0120 |
Periodic oral evaluation - established patient |
2,020 |
2,015 |
$53K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
639 |
297 |
$43K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
385 |
149 |
$39K |
| D7140 |
Extraction, erupted tooth or exposed root |
435 |
231 |
$33K |
| D1351 |
Sealant - per tooth |
945 |
315 |
$30K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,483 |
1,479 |
$26K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
564 |
564 |
$21K |
| D0272 |
Bitewings - two radiographic images |
1,134 |
1,129 |
$20K |
| D0240 |
|
1,028 |
530 |
$16K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
570 |
512 |
$14K |
| D1206 |
Topical application of fluoride varnish |
814 |
811 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
667 |
535 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
145 |
78 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
159 |
158 |
$5K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
62 |
25 |
$4K |
| D1354 |
|
1,495 |
434 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
196 |
80 |
$2K |