| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,662 |
2,623 |
$102K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
913 |
501 |
$64K |
| D0120 |
Periodic oral evaluation - established patient |
2,244 |
2,210 |
$62K |
| D1206 |
Topical application of fluoride varnish |
2,057 |
2,015 |
$55K |
| D7111 |
|
1,156 |
609 |
$51K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,584 |
1,489 |
$43K |
| D1351 |
Sealant - per tooth |
1,940 |
456 |
$40K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
292 |
193 |
$30K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
396 |
279 |
$22K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
298 |
189 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
309 |
307 |
$12K |
| D1208 |
Topical application of fluoride, excluding varnish |
550 |
550 |
$10K |
| D0272 |
Bitewings - two radiographic images |
938 |
938 |
$10K |
| D0330 |
Panoramic radiographic image |
159 |
159 |
$6K |
| D0274 |
Bitewings - four radiographic images |
223 |
222 |
$6K |
| D1330 |
|
371 |
369 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
630 |
626 |
$3K |
| D1110 |
Prophylaxis - adult |
67 |
67 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
405 |
403 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
155 |
153 |
$2K |
| D0602 |
|
146 |
146 |
$1K |
| D0240 |
|
48 |
27 |
$592.80 |