| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
4,927 |
4,921 |
$220K |
| D1206 |
Topical application of fluoride varnish |
3,788 |
3,781 |
$117K |
| D0120 |
Periodic oral evaluation - established patient |
3,633 |
3,631 |
$106K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,277 |
721 |
$91K |
| D1351 |
Sealant - per tooth |
3,279 |
557 |
$65K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,904 |
1,728 |
$47K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
443 |
287 |
$46K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
625 |
622 |
$27K |
| D0272 |
Bitewings - two radiographic images |
2,039 |
2,038 |
$22K |
| D1208 |
Topical application of fluoride, excluding varnish |
853 |
852 |
$21K |
| D7140 |
Extraction, erupted tooth or exposed root |
264 |
154 |
$13K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
63 |
41 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
254 |
252 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
314 |
310 |
$2K |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$144.00 |
| D0603 |
|
12 |
12 |
$120.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
31 |
31 |
$105.00 |