| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
4,396 |
4,378 |
$167K |
| D1206 |
Topical application of fluoride varnish |
3,684 |
3,668 |
$115K |
| D0120 |
Periodic oral evaluation - established patient |
3,664 |
3,648 |
$80K |
| D1351 |
Sealant - per tooth |
3,521 |
806 |
$63K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
584 |
271 |
$27K |
| D9920 |
|
981 |
956 |
$24K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
412 |
149 |
$21K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
859 |
827 |
$17K |
| D0603 |
|
1,857 |
1,845 |
$16K |
| D0272 |
Bitewings - two radiographic images |
1,908 |
1,903 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
333 |
333 |
$6K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
205 |
95 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
207 |
118 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
100 |
61 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
953 |
945 |
$3K |
| D1353 |
|
873 |
192 |
$3K |
| D0602 |
|
405 |
405 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
95 |
93 |
$2K |
| D0330 |
Panoramic radiographic image |
42 |
42 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
63 |
38 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
613 |
611 |
$1K |
| D0145 |
Oral evaluation for a patient under three years of age |
47 |
47 |
$361.25 |
| D0601 |
|
88 |
88 |
$210.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
741 |
741 |
$175.00 |
| D0274 |
Bitewings - four radiographic images |
30 |
30 |
$108.00 |