| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,039 |
2,995 |
$170K |
| D0120 |
Periodic oral evaluation - established patient |
2,454 |
2,453 |
$150K |
| D1206 |
Topical application of fluoride varnish |
3,372 |
3,323 |
$118K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
321 |
212 |
$65K |
| D0272 |
Bitewings - two radiographic images |
1,288 |
1,258 |
$43K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
547 |
517 |
$31K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
136 |
50 |
$29K |
| D0220 |
Intraoral - periapical first radiographic image |
1,292 |
1,282 |
$29K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
695 |
651 |
$29K |
| D1110 |
Prophylaxis - adult |
297 |
297 |
$28K |
| D1351 |
Sealant - per tooth |
532 |
178 |
$25K |
| D0240 |
|
644 |
366 |
$22K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,132 |
953 |
$22K |
| D7140 |
Extraction, erupted tooth or exposed root |
104 |
49 |
$13K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
84 |
64 |
$12K |
| D0274 |
Bitewings - four radiographic images |
188 |
188 |
$11K |
| D0330 |
Panoramic radiographic image |
128 |
128 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
203 |
203 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
95 |
95 |
$6K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
42 |
24 |
$5K |
| D9630 |
|
190 |
189 |
$4K |
| D0145 |
Oral evaluation for a patient under three years of age |
26 |
26 |
$2K |
| D0603 |
|
260 |
257 |
$2K |
| D1330 |
|
343 |
342 |
$1K |
| D0601 |
|
53 |
53 |
$360.00 |
| D0602 |
|
14 |
14 |
$54.00 |
| D1310 |
|
254 |
253 |
$0.00 |
| D9920 |
|
82 |
79 |
$0.00 |
| D1999 |
|
348 |
332 |
$0.00 |