| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,284 |
2,283 |
$83K |
| D0120 |
Periodic oral evaluation - established patient |
2,251 |
2,251 |
$52K |
| D1206 |
Topical application of fluoride varnish |
1,478 |
1,474 |
$38K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
468 |
312 |
$30K |
| D0272 |
Bitewings - two radiographic images |
1,740 |
1,740 |
$20K |
| D0220 |
Intraoral - periapical first radiographic image |
1,346 |
1,340 |
$14K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,015 |
1,014 |
$13K |
| D1351 |
Sealant - per tooth |
463 |
120 |
$11K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
133 |
84 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
181 |
130 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,264 |
1,264 |
$7K |
| D1110 |
Prophylaxis - adult |
162 |
162 |
$7K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
214 |
195 |
$5K |
| D0274 |
Bitewings - four radiographic images |
160 |
160 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
98 |
65 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
37 |
34 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
120 |
120 |
$3K |
| D2332 |
|
22 |
12 |
$2K |
| D0603 |
|
191 |
191 |
$2K |
| D2330 |
|
23 |
14 |
$997.74 |
| D0601 |
|
120 |
120 |
$940.00 |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
28 |
13 |
$845.00 |
| D0145 |
Oral evaluation for a patient under three years of age |
29 |
29 |
$731.00 |
| D0602 |
|
52 |
52 |
$510.00 |