| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
10,236 |
10,016 |
$107K |
| D0120 |
Periodic oral evaluation - established patient |
9,491 |
9,240 |
$62K |
| D1206 |
Topical application of fluoride varnish |
8,338 |
8,199 |
$58K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,242 |
1,385 |
$56K |
| D0272 |
Bitewings - two radiographic images |
8,156 |
7,951 |
$47K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,246 |
2,183 |
$22K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
974 |
390 |
$21K |
| D0220 |
Intraoral - periapical first radiographic image |
7,761 |
7,423 |
$20K |
| D0230 |
Intraoral - periapical each additional radiographic image |
8,003 |
6,412 |
$16K |
| D1110 |
Prophylaxis - adult |
1,363 |
1,321 |
$9K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,904 |
1,769 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
945 |
894 |
$7K |
| D0274 |
Bitewings - four radiographic images |
1,461 |
1,423 |
$7K |
| D1351 |
Sealant - per tooth |
1,207 |
342 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
374 |
204 |
$5K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
211 |
105 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
182 |
118 |
$1K |
| D0330 |
Panoramic radiographic image |
102 |
102 |
$1K |
| D9248 |
|
112 |
100 |
$545.28 |
| D1208 |
Topical application of fluoride, excluding varnish |
3,361 |
3,234 |
$239.02 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
17 |
13 |
$103.37 |
| D1999 |
|
173 |
164 |
$0.00 |
| D0240 |
|
347 |
138 |
$0.00 |
| D0603 |
|
47 |
47 |
$0.00 |
| D0210 |
Intraoral - complete series of radiographic images |
78 |
76 |
$0.00 |