| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,211 |
2,040 |
$109K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
641 |
360 |
$71K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,266 |
1,164 |
$71K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,330 |
2,152 |
$65K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
214 |
100 |
$35K |
| D0120 |
Periodic oral evaluation - established patient |
1,074 |
1,012 |
$30K |
| D0272 |
Bitewings - two radiographic images |
868 |
791 |
$25K |
| D1351 |
Sealant - per tooth |
549 |
163 |
$20K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
232 |
166 |
$20K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
739 |
644 |
$14K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
103 |
56 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
407 |
375 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
68 |
32 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
27 |
25 |
$4K |
| D0274 |
Bitewings - four radiographic images |
69 |
61 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
28 |
28 |
$1K |
| D1110 |
Prophylaxis - adult |
16 |
13 |
$975.00 |
| D1206 |
Topical application of fluoride varnish |
24 |
24 |
$672.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
14 |
14 |
$238.00 |