| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,792 |
3,760 |
$216K |
| D0120 |
Periodic oral evaluation - established patient |
3,606 |
3,569 |
$183K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,697 |
3,659 |
$121K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
446 |
260 |
$78K |
| D0272 |
Bitewings - two radiographic images |
1,741 |
1,725 |
$61K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
998 |
952 |
$60K |
| D0220 |
Intraoral - periapical first radiographic image |
1,189 |
1,168 |
$25K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
190 |
111 |
$24K |
| D1110 |
Prophylaxis - adult |
213 |
212 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
444 |
356 |
$8K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
37 |
15 |
$7K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
45 |
12 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
39 |
39 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
18 |
12 |
$3K |
| D0274 |
Bitewings - four radiographic images |
55 |
55 |
$3K |
| D1999 |
|
329 |
318 |
$1K |
| D0330 |
Panoramic radiographic image |
15 |
15 |
$1K |
| D1206 |
Topical application of fluoride varnish |
25 |
25 |
$768.60 |