| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
5,456 |
5,264 |
$72K |
| D1206 |
Topical application of fluoride varnish |
6,173 |
5,976 |
$42K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,393 |
2,290 |
$37K |
| D0120 |
Periodic oral evaluation - established patient |
4,105 |
3,995 |
$36K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,370 |
4,368 |
$28K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
699 |
422 |
$24K |
| D0272 |
Bitewings - two radiographic images |
3,415 |
3,256 |
$23K |
| D0220 |
Intraoral - periapical first radiographic image |
4,956 |
4,714 |
$22K |
| D1351 |
Sealant - per tooth |
2,660 |
786 |
$22K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
725 |
414 |
$20K |
| D1110 |
Prophylaxis - adult |
997 |
973 |
$17K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
350 |
104 |
$17K |
| D0330 |
Panoramic radiographic image |
1,237 |
1,181 |
$11K |
| D0274 |
Bitewings - four radiographic images |
903 |
880 |
$10K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
915 |
846 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
276 |
137 |
$7K |
| D0350 |
|
637 |
601 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
127 |
120 |
$2K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
22 |
12 |
$645.26 |
| D1330 |
|
2,675 |
2,487 |
$0.00 |