| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,565 |
2,559 |
$92K |
| D0120 |
Periodic oral evaluation - established patient |
2,479 |
2,469 |
$58K |
| D7140 |
Extraction, erupted tooth or exposed root |
828 |
514 |
$35K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,191 |
2,184 |
$27K |
| D1351 |
Sealant - per tooth |
672 |
232 |
$25K |
| D1110 |
Prophylaxis - adult |
562 |
559 |
$24K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
418 |
257 |
$24K |
| D1206 |
Topical application of fluoride varnish |
836 |
835 |
$22K |
| D0274 |
Bitewings - four radiographic images |
715 |
713 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
1,432 |
1,427 |
$17K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
581 |
580 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,140 |
1,135 |
$13K |
| D0272 |
Bitewings - two radiographic images |
729 |
729 |
$10K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
102 |
56 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
150 |
102 |
$7K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
108 |
56 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
57 |
29 |
$4K |
| D2335 |
|
22 |
12 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
78 |
68 |
$2K |
| D2332 |
|
23 |
12 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
52 |
52 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
50 |
50 |
$586.15 |
| D9991 |
|
57 |
55 |
$557.00 |
| D1320 |
|
48 |
48 |
$384.00 |