| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,266 |
1,265 |
$61K |
| D0120 |
Periodic oral evaluation - established patient |
1,573 |
1,570 |
$51K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
470 |
204 |
$50K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,426 |
1,423 |
$33K |
| D0272 |
Bitewings - two radiographic images |
1,217 |
1,215 |
$32K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
198 |
106 |
$30K |
| D0220 |
Intraoral - periapical first radiographic image |
1,788 |
1,753 |
$29K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
318 |
168 |
$28K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
236 |
113 |
$23K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,734 |
1,577 |
$22K |
| D1110 |
Prophylaxis - adult |
312 |
310 |
$18K |
| D0274 |
Bitewings - four radiographic images |
277 |
276 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
187 |
187 |
$9K |
| D1206 |
Topical application of fluoride varnish |
229 |
229 |
$6K |
| D1351 |
Sealant - per tooth |
149 |
50 |
$5K |
| D9248 |
|
58 |
55 |
$4K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
126 |
122 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
30 |
17 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
64 |
64 |
$3K |
| D0603 |
|
404 |
402 |
$0.00 |
| D0601 |
|
52 |
52 |
$0.00 |
| D0602 |
|
523 |
520 |
$0.00 |