| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
4,662 |
4,594 |
$152K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,316 |
771 |
$114K |
| D1206 |
Topical application of fluoride varnish |
5,572 |
5,487 |
$112K |
| D0120 |
Periodic oral evaluation - established patient |
4,499 |
4,430 |
$88K |
| D9920 |
|
1,331 |
1,279 |
$86K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,577 |
1,367 |
$51K |
| D1351 |
Sealant - per tooth |
1,580 |
475 |
$49K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
333 |
155 |
$46K |
| D0272 |
Bitewings - two radiographic images |
1,947 |
1,922 |
$39K |
| D1110 |
Prophylaxis - adult |
742 |
728 |
$34K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,018 |
1,000 |
$31K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
374 |
261 |
$28K |
| D0140 |
Limited oral evaluation - problem focused |
344 |
327 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
101 |
61 |
$7K |
| D0274 |
Bitewings - four radiographic images |
230 |
226 |
$6K |
| D0330 |
Panoramic radiographic image |
95 |
87 |
$5K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
27 |
13 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
25 |
24 |
$678.30 |
| D0220 |
Intraoral - periapical first radiographic image |
59 |
53 |
$659.62 |
| D0240 |
|
40 |
32 |
$490.80 |