| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,955 |
1,598 |
$84K |
| D1206 |
Topical application of fluoride varnish |
1,735 |
1,406 |
$72K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,092 |
341 |
$40K |
| D1351 |
Sealant - per tooth |
2,070 |
486 |
$35K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
539 |
137 |
$30K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,017 |
849 |
$26K |
| D0120 |
Periodic oral evaluation - established patient |
902 |
758 |
$18K |
| D0272 |
Bitewings - two radiographic images |
1,067 |
880 |
$18K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
556 |
249 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,265 |
1,266 |
$14K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
236 |
112 |
$10K |
| D9248 |
|
162 |
114 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
1,019 |
826 |
$10K |
| D0330 |
Panoramic radiographic image |
258 |
216 |
$9K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
490 |
365 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
176 |
86 |
$6K |
| D0274 |
Bitewings - four radiographic images |
324 |
264 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
173 |
159 |
$5K |
| D0145 |
Oral evaluation for a patient under three years of age |
223 |
173 |
$3K |
| D0170 |
|
273 |
203 |
$3K |
| D1110 |
Prophylaxis - adult |
59 |
59 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
321 |
290 |
$2K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
53 |
25 |
$2K |
| D3120 |
|
99 |
30 |
$246.00 |