| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,683 |
3,505 |
$167K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
2,155 |
954 |
$161K |
| D0120 |
Periodic oral evaluation - established patient |
3,714 |
3,475 |
$77K |
| D9248 |
|
704 |
611 |
$67K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,098 |
3,826 |
$59K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
753 |
408 |
$48K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,571 |
1,294 |
$48K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
420 |
259 |
$42K |
| D1110 |
Prophylaxis - adult |
876 |
767 |
$32K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,140 |
1,066 |
$28K |
| D0272 |
Bitewings - two radiographic images |
1,613 |
1,499 |
$27K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
369 |
230 |
$21K |
| D1351 |
Sealant - per tooth |
875 |
213 |
$15K |
| D7140 |
Extraction, erupted tooth or exposed root |
338 |
184 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
1,147 |
1,065 |
$11K |
| D2332 |
|
138 |
89 |
$11K |
| D1206 |
Topical application of fluoride varnish |
560 |
538 |
$9K |
| D0330 |
Panoramic radiographic image |
197 |
181 |
$7K |
| D0274 |
Bitewings - four radiographic images |
191 |
169 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
84 |
54 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
492 |
234 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
34 |
32 |
$756.15 |
| D1330 |
|
95 |
86 |
$0.00 |