| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,326 |
1,325 |
$55K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
420 |
341 |
$50K |
| D0120 |
Periodic oral evaluation - established patient |
1,511 |
1,511 |
$43K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,616 |
1,615 |
$22K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
249 |
207 |
$18K |
| D1110 |
Prophylaxis - adult |
289 |
289 |
$16K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
79 |
67 |
$14K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
88 |
75 |
$12K |
| D0330 |
Panoramic radiographic image |
220 |
220 |
$8K |
| D1351 |
Sealant - per tooth |
121 |
104 |
$8K |
| D0272 |
Bitewings - two radiographic images |
403 |
403 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
42 |
38 |
$3K |
| D0274 |
Bitewings - four radiographic images |
45 |
45 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
13 |
13 |
$120.00 |
| D1320 |
|
179 |
179 |
$0.00 |
| D1310 |
|
28 |
28 |
$0.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
364 |
330 |
$0.00 |