| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
6,248 |
6,176 |
$55K |
| D1206 |
Topical application of fluoride varnish |
7,045 |
6,954 |
$31K |
| D0120 |
Periodic oral evaluation - established patient |
5,384 |
5,329 |
$29K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,186 |
636 |
$27K |
| D0220 |
Intraoral - periapical first radiographic image |
6,882 |
6,757 |
$18K |
| D0272 |
Bitewings - two radiographic images |
4,159 |
4,104 |
$18K |
| D0230 |
Intraoral - periapical each additional radiographic image |
7,108 |
6,320 |
$15K |
| D1351 |
Sealant - per tooth |
2,142 |
664 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
923 |
902 |
$11K |
| D0274 |
Bitewings - four radiographic images |
1,312 |
1,290 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
541 |
330 |
$7K |
| D1110 |
Prophylaxis - adult |
610 |
598 |
$7K |
| D0330 |
Panoramic radiographic image |
993 |
984 |
$6K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,449 |
1,370 |
$6K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
229 |
115 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
224 |
146 |
$4K |
| D0145 |
Oral evaluation for a patient under three years of age |
502 |
498 |
$4K |
| D9248 |
|
77 |
71 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
137 |
134 |
$876.36 |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
16 |
12 |
$284.60 |
| D0602 |
|
80 |
77 |
$0.00 |
| D0603 |
|
12 |
12 |
$0.00 |