| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,907 |
1,903 |
$92K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,162 |
703 |
$75K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
897 |
896 |
$59K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,319 |
1,155 |
$52K |
| D1310 |
|
1,247 |
1,233 |
$42K |
| D1206 |
Topical application of fluoride varnish |
1,880 |
1,879 |
$42K |
| D0120 |
Periodic oral evaluation - established patient |
623 |
623 |
$37K |
| D9430 |
|
1,140 |
996 |
$36K |
| D0145 |
Oral evaluation for a patient under three years of age |
408 |
408 |
$26K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,344 |
1,166 |
$22K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
167 |
129 |
$20K |
| D1351 |
Sealant - per tooth |
459 |
169 |
$17K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
109 |
88 |
$8K |
| D0272 |
Bitewings - two radiographic images |
669 |
666 |
$8K |
| D0602 |
|
399 |
399 |
$6K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
50 |
42 |
$5K |
| D0603 |
|
343 |
343 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
76 |
56 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
318 |
314 |
$4K |
| D0601 |
|
156 |
156 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
34 |
27 |
$2K |
| D0274 |
Bitewings - four radiographic images |
116 |
116 |
$583.20 |
| D0350 |
|
109 |
68 |
$345.60 |
| D0270 |
|
33 |
33 |
$165.00 |
| D1330 |
|
393 |
392 |
$0.00 |