| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
4,072 |
3,947 |
$26K |
| D0120 |
Periodic oral evaluation - established patient |
3,898 |
3,799 |
$16K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
636 |
234 |
$11K |
| D0272 |
Bitewings - two radiographic images |
2,915 |
2,827 |
$10K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
184 |
51 |
$8K |
| D1206 |
Topical application of fluoride varnish |
1,697 |
1,694 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,693 |
2,573 |
$6K |
| D1351 |
Sealant - per tooth |
696 |
193 |
$3K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
28 |
12 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
458 |
429 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
124 |
63 |
$2K |
| D0274 |
Bitewings - four radiographic images |
338 |
330 |
$1K |
| D0240 |
|
625 |
290 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
58 |
26 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
514 |
463 |
$1K |
| D1110 |
Prophylaxis - adult |
105 |
105 |
$307.20 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
155 |
146 |
$187.38 |
| D0230 |
Intraoral - periapical each additional radiographic image |
68 |
51 |
$171.39 |
| D0140 |
Limited oral evaluation - problem focused |
77 |
70 |
$170.39 |
| D1354 |
|
107 |
13 |
$110.28 |
| D0210 |
Intraoral - complete series of radiographic images |
14 |
13 |
$0.00 |
| D9248 |
|
15 |
15 |
$0.00 |