| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,967 |
1,927 |
$106K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
489 |
263 |
$82K |
| D0120 |
Periodic oral evaluation - established patient |
1,601 |
1,574 |
$77K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,859 |
1,787 |
$57K |
| D0272 |
Bitewings - two radiographic images |
1,166 |
1,146 |
$37K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
419 |
404 |
$27K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
171 |
119 |
$21K |
| D1351 |
Sealant - per tooth |
535 |
153 |
$20K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
123 |
54 |
$18K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
759 |
680 |
$17K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
68 |
24 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
587 |
571 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
326 |
282 |
$6K |
| D1206 |
Topical application of fluoride varnish |
198 |
186 |
$5K |
| D9420 |
|
12 |
12 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
19 |
12 |
$2K |
| D1110 |
Prophylaxis - adult |
25 |
25 |
$2K |
| D0330 |
Panoramic radiographic image |
29 |
29 |
$1K |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$656.10 |
| D1999 |
|
46 |
46 |
$190.40 |