| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
7,904 |
7,698 |
$196K |
| D0120 |
Periodic oral evaluation - established patient |
8,519 |
8,311 |
$150K |
| D1206 |
Topical application of fluoride varnish |
9,278 |
8,990 |
$136K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,824 |
1,692 |
$80K |
| D0272 |
Bitewings - two radiographic images |
3,307 |
3,203 |
$51K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
627 |
273 |
$50K |
| D0220 |
Intraoral - periapical first radiographic image |
4,185 |
4,021 |
$39K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,752 |
3,478 |
$26K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
116 |
24 |
$25K |
| D1351 |
Sealant - per tooth |
703 |
217 |
$15K |
| D1110 |
Prophylaxis - adult |
441 |
436 |
$12K |
| D9420 |
|
62 |
56 |
$12K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
52 |
13 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
74 |
70 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
30 |
13 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
12 |
$507.21 |