| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
12,246 |
12,243 |
$344K |
| D0120 |
Periodic oral evaluation - established patient |
12,414 |
12,414 |
$340K |
| D0240 |
|
11,096 |
11,090 |
$235K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,485 |
1,614 |
$173K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,952 |
2,729 |
$169K |
| D0220 |
Intraoral - periapical first radiographic image |
13,401 |
13,351 |
$154K |
| D0272 |
Bitewings - two radiographic images |
7,418 |
7,417 |
$140K |
| D1206 |
Topical application of fluoride varnish |
6,520 |
6,520 |
$125K |
| D0274 |
Bitewings - four radiographic images |
4,050 |
4,050 |
$116K |
| D0230 |
Intraoral - periapical each additional radiographic image |
13,205 |
6,057 |
$112K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,284 |
705 |
$109K |
| D0330 |
Panoramic radiographic image |
1,488 |
1,488 |
$81K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,469 |
1,060 |
$80K |
| D1208 |
Topical application of fluoride, excluding varnish |
7,597 |
7,595 |
$73K |
| D1110 |
Prophylaxis - adult |
1,662 |
1,661 |
$61K |
| D0145 |
Oral evaluation for a patient under three years of age |
766 |
766 |
$23K |
| D7140 |
Extraction, erupted tooth or exposed root |
503 |
332 |
$23K |
| D1351 |
Sealant - per tooth |
863 |
265 |
$23K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
117 |
95 |
$9K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
132 |
99 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
239 |
229 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
119 |
119 |
$4K |
| D1354 |
|
96 |
27 |
$607.68 |