| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,578 |
3,249 |
$138K |
| D1206 |
Topical application of fluoride varnish |
3,523 |
3,202 |
$85K |
| D0120 |
Periodic oral evaluation - established patient |
3,015 |
2,737 |
$81K |
| D1351 |
Sealant - per tooth |
697 |
373 |
$35K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
763 |
566 |
$19K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
329 |
224 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
231 |
166 |
$13K |
| D1354 |
|
395 |
274 |
$11K |
| D7140 |
Extraction, erupted tooth or exposed root |
196 |
155 |
$9K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
79 |
56 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
293 |
264 |
$6K |
| D0272 |
Bitewings - two radiographic images |
501 |
444 |
$5K |
| D0274 |
Bitewings - four radiographic images |
273 |
245 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
374 |
326 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
99 |
90 |
$2K |
| D0330 |
Panoramic radiographic image |
81 |
63 |
$1K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
16 |
13 |
$843.20 |
| D0210 |
Intraoral - complete series of radiographic images |
60 |
47 |
$840.40 |
| D0230 |
Intraoral - periapical each additional radiographic image |
74 |
54 |
$509.20 |
| D0603 |
|
836 |
744 |
$0.00 |
| D0601 |
|
973 |
868 |
$0.00 |
| D0602 |
|
740 |
670 |
$0.00 |