| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,513 |
2,501 |
$106K |
| D0120 |
Periodic oral evaluation - established patient |
3,313 |
3,295 |
$96K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,476 |
3,456 |
$80K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
412 |
281 |
$49K |
| D1110 |
Prophylaxis - adult |
817 |
809 |
$47K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
188 |
83 |
$29K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
114 |
95 |
$17K |
| D0272 |
Bitewings - two radiographic images |
1,132 |
1,127 |
$17K |
| D1351 |
Sealant - per tooth |
378 |
127 |
$13K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
194 |
81 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
118 |
93 |
$11K |
| D7140 |
Extraction, erupted tooth or exposed root |
85 |
61 |
$9K |
| D0274 |
Bitewings - four radiographic images |
385 |
385 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
107 |
107 |
$5K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
305 |
276 |
$5K |
| D1330 |
|
768 |
767 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
91 |
90 |
$4K |
| D0240 |
|
99 |
98 |
$891.00 |
| D0220 |
Intraoral - periapical first radiographic image |
74 |
74 |
$666.00 |