| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,093 |
2,937 |
$118K |
| D0120 |
Periodic oral evaluation - established patient |
3,835 |
3,606 |
$93K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
836 |
338 |
$87K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
623 |
155 |
$86K |
| D1206 |
Topical application of fluoride varnish |
3,872 |
3,663 |
$69K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,045 |
885 |
$38K |
| D1110 |
Prophylaxis - adult |
926 |
857 |
$33K |
| D0210 |
Intraoral - complete series of radiographic images |
469 |
441 |
$30K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
355 |
165 |
$30K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
297 |
65 |
$28K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
794 |
756 |
$24K |
| D0272 |
Bitewings - two radiographic images |
1,164 |
1,112 |
$18K |
| D1351 |
Sealant - per tooth |
679 |
183 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
1,104 |
998 |
$11K |
| D7140 |
Extraction, erupted tooth or exposed root |
125 |
39 |
$5K |
| D0274 |
Bitewings - four radiographic images |
286 |
272 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
288 |
241 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
50 |
42 |
$910.92 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$693.32 |
| D1320 |
|
204 |
178 |
$540.22 |
| D1999 |
|
149 |
142 |
$0.00 |