| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,308 |
2,297 |
$113K |
| D1206 |
Topical application of fluoride varnish |
2,287 |
2,276 |
$74K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
737 |
459 |
$62K |
| D0120 |
Periodic oral evaluation - established patient |
1,841 |
1,838 |
$61K |
| D9248 |
|
207 |
201 |
$51K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
199 |
164 |
$33K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
923 |
874 |
$28K |
| D1351 |
Sealant - per tooth |
826 |
212 |
$26K |
| D0140 |
Limited oral evaluation - problem focused |
405 |
402 |
$21K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
407 |
407 |
$16K |
| D0272 |
Bitewings - two radiographic images |
900 |
890 |
$15K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
146 |
122 |
$14K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
151 |
113 |
$11K |
| D7140 |
Extraction, erupted tooth or exposed root |
122 |
94 |
$10K |
| D0603 |
|
1,134 |
1,126 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
753 |
737 |
$6K |
| D0330 |
Panoramic radiographic image |
88 |
88 |
$5K |
| D0602 |
|
530 |
530 |
$4K |
| D0240 |
|
173 |
171 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
379 |
379 |
$3K |
| D0601 |
|
228 |
228 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
15 |
13 |
$1K |
| D0145 |
Oral evaluation for a patient under three years of age |
14 |
14 |
$585.00 |
| D0274 |
Bitewings - four radiographic images |
13 |
13 |
$156.00 |
| D1330 |
|
204 |
202 |
$0.00 |
| D1310 |
|
26 |
26 |
$0.00 |