| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
4,889 |
4,889 |
$122K |
| D0120 |
Periodic oral evaluation - established patient |
4,439 |
4,439 |
$106K |
| D1206 |
Topical application of fluoride varnish |
5,124 |
5,124 |
$92K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,047 |
690 |
$64K |
| D1351 |
Sealant - per tooth |
2,621 |
469 |
$44K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
609 |
457 |
$44K |
| D7140 |
Extraction, erupted tooth or exposed root |
505 |
326 |
$28K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,093 |
1,049 |
$25K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
655 |
655 |
$23K |
| D0272 |
Bitewings - two radiographic images |
2,326 |
2,326 |
$20K |
| D0140 |
Limited oral evaluation - problem focused |
773 |
743 |
$11K |
| D0330 |
Panoramic radiographic image |
347 |
347 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
165 |
99 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
1,047 |
1,037 |
$7K |
| D1110 |
Prophylaxis - adult |
173 |
173 |
$5K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
83 |
49 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
663 |
663 |
$4K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
25 |
15 |
$3K |
| D2335 |
|
27 |
15 |
$2K |