| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,515 |
2,511 |
$126K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,751 |
958 |
$114K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,425 |
1,424 |
$93K |
| D0120 |
Periodic oral evaluation - established patient |
787 |
786 |
$53K |
| D1206 |
Topical application of fluoride varnish |
2,490 |
2,487 |
$50K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
932 |
520 |
$50K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,244 |
1,068 |
$49K |
| D1351 |
Sealant - per tooth |
1,194 |
375 |
$45K |
| D0230 |
Intraoral - periapical each additional radiographic image |
10,328 |
1,913 |
$41K |
| D1310 |
|
840 |
836 |
$38K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
247 |
174 |
$29K |
| D0350 |
|
2,554 |
1,163 |
$24K |
| D7140 |
Extraction, erupted tooth or exposed root |
410 |
290 |
$23K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
266 |
195 |
$21K |
| D0145 |
Oral evaluation for a patient under three years of age |
253 |
253 |
$17K |
| D9430 |
|
471 |
425 |
$15K |
| D0272 |
Bitewings - two radiographic images |
1,037 |
1,037 |
$12K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
97 |
67 |
$9K |
| D0274 |
Bitewings - four radiographic images |
335 |
335 |
$7K |
| D0603 |
|
411 |
410 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
165 |
165 |
$6K |
| D0330 |
Panoramic radiographic image |
166 |
166 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
103 |
102 |
$5K |
| D0601 |
|
263 |
261 |
$4K |
| D1354 |
|
62 |
24 |
$744.00 |
| D0602 |
|
13 |
13 |
$180.00 |