| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,951 |
1,940 |
$69K |
| D1206 |
Topical application of fluoride varnish |
2,240 |
2,217 |
$48K |
| D0120 |
Periodic oral evaluation - established patient |
1,534 |
1,518 |
$38K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
220 |
67 |
$28K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
520 |
488 |
$26K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,047 |
1,040 |
$24K |
| D0274 |
Bitewings - four radiographic images |
713 |
712 |
$21K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
250 |
167 |
$19K |
| D7140 |
Extraction, erupted tooth or exposed root |
241 |
122 |
$18K |
| D0240 |
|
814 |
616 |
$16K |
| D1110 |
Prophylaxis - adult |
345 |
345 |
$14K |
| D1351 |
Sealant - per tooth |
492 |
109 |
$13K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
184 |
133 |
$11K |
| D0272 |
Bitewings - two radiographic images |
470 |
469 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
200 |
199 |
$4K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
22 |
13 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
31 |
31 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
31 |
31 |
$2K |
| D1330 |
|
123 |
123 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
167 |
165 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
44 |
42 |
$628.00 |
| D0145 |
Oral evaluation for a patient under three years of age |
12 |
12 |
$260.00 |
| D0601 |
|
56 |
56 |
$0.00 |
| D0602 |
|
137 |
136 |
$0.00 |
| D0603 |
|
208 |
206 |
$0.00 |