| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,452 |
3,428 |
$102K |
| D1206 |
Topical application of fluoride varnish |
4,465 |
4,435 |
$81K |
| D0120 |
Periodic oral evaluation - established patient |
4,357 |
4,328 |
$76K |
| D1110 |
Prophylaxis - adult |
1,012 |
1,009 |
$39K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
474 |
250 |
$32K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
337 |
98 |
$18K |
| D9310 |
|
529 |
523 |
$16K |
| D0272 |
Bitewings - two radiographic images |
865 |
859 |
$16K |
| D9248 |
|
177 |
172 |
$13K |
| D7140 |
Extraction, erupted tooth or exposed root |
298 |
139 |
$9K |
| D0274 |
Bitewings - four radiographic images |
379 |
379 |
$9K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
235 |
222 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
874 |
857 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
839 |
319 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
24 |
12 |
$3K |
| D0240 |
|
243 |
125 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
13 |
13 |
$375.72 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
21 |
12 |
$0.00 |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
59 |
27 |
$0.00 |
| D9999 |
Unspecified adjunctive procedure, by report |
12 |
12 |
$0.00 |