| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
4,458 |
4,457 |
$167K |
| D0120 |
Periodic oral evaluation - established patient |
3,166 |
3,166 |
$111K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,242 |
808 |
$101K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,299 |
4,298 |
$88K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
679 |
678 |
$28K |
| D0272 |
Bitewings - two radiographic images |
1,327 |
1,327 |
$27K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
502 |
272 |
$24K |
| D7140 |
Extraction, erupted tooth or exposed root |
288 |
182 |
$14K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
91 |
66 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
998 |
991 |
$9K |
| D0603 |
|
815 |
815 |
$8K |
| D0240 |
|
551 |
549 |
$6K |
| D1351 |
Sealant - per tooth |
221 |
37 |
$5K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
180 |
177 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
388 |
387 |
$4K |
| D0145 |
Oral evaluation for a patient under three years of age |
55 |
55 |
$2K |
| D1206 |
Topical application of fluoride varnish |
100 |
100 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
68 |
68 |
$2K |
| D1510 |
|
13 |
12 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
15 |
12 |
$1K |
| D1330 |
|
12 |
12 |
$0.00 |