| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,404 |
1,376 |
$56K |
| D1206 |
Topical application of fluoride varnish |
1,059 |
1,031 |
$34K |
| D0120 |
Periodic oral evaluation - established patient |
863 |
852 |
$24K |
| D1351 |
Sealant - per tooth |
1,732 |
323 |
$22K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
527 |
208 |
$21K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
582 |
566 |
$13K |
| D0274 |
Bitewings - four radiographic images |
542 |
520 |
$9K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
162 |
64 |
$9K |
| D0330 |
Panoramic radiographic image |
238 |
225 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
193 |
96 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
211 |
116 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
368 |
368 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,217 |
723 |
$5K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
372 |
339 |
$5K |
| D1110 |
Prophylaxis - adult |
72 |
72 |
$4K |
| D0272 |
Bitewings - two radiographic images |
228 |
226 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
367 |
352 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
47 |
30 |
$3K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
54 |
28 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
53 |
50 |
$1K |
| D1353 |
|
37 |
12 |
$508.40 |
| D0601 |
|
65 |
60 |
$240.00 |
| D0602 |
|
49 |
46 |
$195.00 |
| D0603 |
|
43 |
41 |
$185.00 |