| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
5,028 |
5,006 |
$175K |
| D0120 |
Periodic oral evaluation - established patient |
5,363 |
5,343 |
$148K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
790 |
577 |
$68K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
411 |
276 |
$55K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,785 |
3,766 |
$53K |
| D1110 |
Prophylaxis - adult |
917 |
915 |
$47K |
| D0272 |
Bitewings - two radiographic images |
1,816 |
1,806 |
$40K |
| D1351 |
Sealant - per tooth |
1,386 |
373 |
$37K |
| D1206 |
Topical application of fluoride varnish |
2,093 |
2,088 |
$29K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,119 |
998 |
$29K |
| D0274 |
Bitewings - four radiographic images |
674 |
669 |
$22K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
624 |
619 |
$21K |
| D0330 |
Panoramic radiographic image |
349 |
349 |
$21K |
| D0220 |
Intraoral - periapical first radiographic image |
1,559 |
1,530 |
$18K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
200 |
142 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
705 |
259 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
187 |
184 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
45 |
28 |
$2K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
15 |
12 |
$1K |
| D0270 |
|
186 |
184 |
$867.30 |
| D0602 |
|
581 |
579 |
$0.00 |
| D0603 |
|
1,652 |
1,649 |
$0.00 |
| D0601 |
|
3,714 |
3,691 |
$0.00 |