| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
4,864 |
4,773 |
$171K |
| D0120 |
Periodic oral evaluation - established patient |
5,667 |
5,570 |
$159K |
| D1351 |
Sealant - per tooth |
5,063 |
1,322 |
$134K |
| D0145 |
Oral evaluation for a patient under three years of age |
727 |
716 |
$100K |
| D1110 |
Prophylaxis - adult |
1,800 |
1,771 |
$94K |
| D0230 |
Intraoral - periapical each additional radiographic image |
8,313 |
5,402 |
$92K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
970 |
475 |
$90K |
| D1208 |
Topical application of fluoride, excluding varnish |
6,247 |
6,143 |
$89K |
| D0272 |
Bitewings - two radiographic images |
3,792 |
3,718 |
$86K |
| D0220 |
Intraoral - periapical first radiographic image |
5,846 |
5,712 |
$71K |
| D0274 |
Bitewings - four radiographic images |
1,617 |
1,594 |
$54K |
| D0210 |
Intraoral - complete series of radiographic images |
774 |
757 |
$52K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
278 |
63 |
$39K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,030 |
1,007 |
$34K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
393 |
387 |
$10K |
| D9248 |
|
70 |
68 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
76 |
55 |
$6K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
43 |
12 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
31 |
13 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
26 |
25 |
$488.28 |
| D0603 |
|
6,330 |
6,250 |
$0.00 |
| D0602 |
|
824 |
821 |
$0.00 |
| D0601 |
|
97 |
92 |
$0.00 |