| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,584 |
3,440 |
$163K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,434 |
773 |
$93K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,426 |
3,299 |
$86K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
711 |
227 |
$81K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,986 |
3,828 |
$59K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,228 |
1,150 |
$44K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
431 |
146 |
$28K |
| D0272 |
Bitewings - two radiographic images |
1,546 |
1,474 |
$27K |
| D9420 |
|
224 |
215 |
$14K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
180 |
105 |
$9K |
| D7140 |
Extraction, erupted tooth or exposed root |
189 |
91 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
316 |
308 |
$7K |
| D0330 |
Panoramic radiographic image |
175 |
168 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
310 |
295 |
$3K |
| D1351 |
Sealant - per tooth |
123 |
38 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
15 |
12 |
$1K |
| D0274 |
Bitewings - four radiographic images |
44 |
42 |
$1K |
| D9986 |
|
1,154 |
976 |
$621.00 |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$553.16 |