| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
3,191 |
3,147 |
$82K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
723 |
461 |
$73K |
| D1120 |
Prophylaxis - child |
2,329 |
2,292 |
$61K |
| D1206 |
Topical application of fluoride varnish |
3,234 |
3,178 |
$51K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,083 |
1,021 |
$46K |
| D1110 |
Prophylaxis - adult |
926 |
914 |
$35K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
378 |
251 |
$28K |
| D1351 |
Sealant - per tooth |
871 |
359 |
$24K |
| D0272 |
Bitewings - two radiographic images |
1,162 |
1,137 |
$21K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
107 |
63 |
$16K |
| D0274 |
Bitewings - four radiographic images |
383 |
379 |
$12K |
| D9420 |
|
56 |
52 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
124 |
124 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
364 |
356 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
68 |
41 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
20 |
12 |
$3K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
30 |
15 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
34 |
13 |
$427.72 |