| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
4,146 |
4,136 |
$213K |
| D1310 |
|
2,895 |
2,884 |
$132K |
| D0120 |
Periodic oral evaluation - established patient |
1,718 |
1,709 |
$106K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,893 |
3,880 |
$95K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,401 |
1,400 |
$93K |
| D0145 |
Oral evaluation for a patient under three years of age |
1,001 |
1,000 |
$65K |
| D0230 |
Intraoral - periapical each additional radiographic image |
15,088 |
3,426 |
$64K |
| D1351 |
Sealant - per tooth |
1,196 |
277 |
$45K |
| D0603 |
|
2,786 |
2,776 |
$41K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
635 |
302 |
$41K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
262 |
132 |
$31K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
286 |
142 |
$28K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
701 |
644 |
$27K |
| D0272 |
Bitewings - two radiographic images |
1,677 |
1,671 |
$19K |
| D0220 |
Intraoral - periapical first radiographic image |
1,374 |
1,352 |
$16K |
| D0350 |
|
1,171 |
511 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
207 |
126 |
$10K |
| D0274 |
Bitewings - four radiographic images |
437 |
437 |
$9K |
| D1206 |
Topical application of fluoride varnish |
193 |
193 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
49 |
26 |
$3K |
| D9430 |
|
55 |
53 |
$2K |
| D0602 |
|
26 |
26 |
$390.00 |