| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,686 |
3,535 |
$111K |
| D1206 |
Topical application of fluoride varnish |
5,195 |
4,936 |
$101K |
| D0120 |
Periodic oral evaluation - established patient |
4,146 |
3,934 |
$91K |
| D1110 |
Prophylaxis - adult |
2,341 |
2,222 |
$91K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,086 |
578 |
$63K |
| D9248 |
|
593 |
534 |
$44K |
| D0274 |
Bitewings - four radiographic images |
1,636 |
1,526 |
$36K |
| D0330 |
Panoramic radiographic image |
948 |
896 |
$32K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
462 |
285 |
$31K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
287 |
122 |
$29K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
971 |
906 |
$26K |
| D0272 |
Bitewings - two radiographic images |
1,366 |
1,316 |
$20K |
| D0220 |
Intraoral - periapical first radiographic image |
1,040 |
982 |
$12K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
147 |
72 |
$11K |
| D7140 |
Extraction, erupted tooth or exposed root |
162 |
80 |
$9K |
| D1351 |
Sealant - per tooth |
260 |
79 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
166 |
157 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
253 |
177 |
$2K |
| D8670 |
Periodic orthodontic treatment visit |
17 |
12 |
$1K |
| D1354 |
|
36 |
15 |
$346.85 |