| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
5,067 |
5,063 |
$173K |
| D0120 |
Periodic oral evaluation - established patient |
6,057 |
6,053 |
$139K |
| D1351 |
Sealant - per tooth |
970 |
610 |
$70K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,997 |
4,996 |
$56K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
535 |
508 |
$52K |
| D1110 |
Prophylaxis - adult |
1,081 |
1,081 |
$50K |
| D0272 |
Bitewings - two radiographic images |
2,572 |
2,565 |
$33K |
| D1206 |
Topical application of fluoride varnish |
1,074 |
1,071 |
$26K |
| D0220 |
Intraoral - periapical first radiographic image |
1,265 |
1,253 |
$14K |
| D0330 |
Panoramic radiographic image |
363 |
363 |
$12K |
| D7140 |
Extraction, erupted tooth or exposed root |
123 |
112 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
165 |
165 |
$4K |
| D0240 |
|
225 |
224 |
$3K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
28 |
27 |
$2K |
| D0274 |
Bitewings - four radiographic images |
98 |
98 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
25 |
24 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
88 |
85 |
$879.50 |
| D9996 |
|
18 |
16 |
$226.08 |
| D1330 |
|
2,957 |
2,954 |
$0.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
39 |
36 |
$0.00 |
| D1999 |
|
203 |
196 |
$0.00 |