| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
4,165 |
4,164 |
$167K |
| D0120 |
Periodic oral evaluation - established patient |
3,396 |
3,395 |
$90K |
| D1206 |
Topical application of fluoride varnish |
1,679 |
1,679 |
$44K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,090 |
2,089 |
$27K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
385 |
210 |
$22K |
| D0272 |
Bitewings - two radiographic images |
1,318 |
1,317 |
$21K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
743 |
743 |
$20K |
| D1351 |
Sealant - per tooth |
507 |
139 |
$20K |
| D1110 |
Prophylaxis - adult |
262 |
261 |
$14K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
141 |
83 |
$6K |
| D0330 |
Panoramic radiographic image |
90 |
90 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
62 |
39 |
$3K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
33 |
14 |
$3K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
19 |
12 |
$570.27 |
| D0140 |
Limited oral evaluation - problem focused |
18 |
18 |
$212.80 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
286 |
281 |
$192.00 |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$133.00 |
| D1330 |
|
12 |
12 |
$0.00 |
| D1310 |
|
31 |
31 |
$0.00 |