| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
5,836 |
5,827 |
$261K |
| D1206 |
Topical application of fluoride varnish |
5,752 |
5,743 |
$179K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,376 |
1,601 |
$174K |
| D0120 |
Periodic oral evaluation - established patient |
4,222 |
4,214 |
$106K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
780 |
423 |
$88K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,043 |
798 |
$61K |
| D0272 |
Bitewings - two radiographic images |
4,793 |
4,786 |
$58K |
| D1351 |
Sealant - per tooth |
1,997 |
649 |
$43K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,311 |
1,311 |
$33K |
| D0603 |
|
2,734 |
2,734 |
$27K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,072 |
994 |
$26K |
| D0220 |
Intraoral - periapical first radiographic image |
3,463 |
3,435 |
$23K |
| D7140 |
Extraction, erupted tooth or exposed root |
418 |
306 |
$21K |
| D0140 |
Limited oral evaluation - problem focused |
401 |
400 |
$17K |
| D1354 |
|
1,569 |
580 |
$15K |
| D0330 |
Panoramic radiographic image |
366 |
366 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,206 |
2,204 |
$14K |
| D2332 |
|
72 |
52 |
$5K |
| D0602 |
|
270 |
270 |
$3K |
| D2330 |
|
44 |
28 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
13 |
12 |
$1K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
16 |
12 |
$1K |
| D0601 |
|
95 |
95 |
$950.00 |