| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,911 |
1,909 |
$97K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
758 |
758 |
$50K |
| D1310 |
|
958 |
958 |
$41K |
| D0120 |
Periodic oral evaluation - established patient |
449 |
448 |
$25K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,394 |
1,358 |
$22K |
| D1208 |
Topical application of fluoride, excluding varnish |
768 |
767 |
$19K |
| D1351 |
Sealant - per tooth |
486 |
125 |
$18K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
409 |
386 |
$16K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
234 |
106 |
$16K |
| D1206 |
Topical application of fluoride varnish |
704 |
704 |
$13K |
| D0340 |
|
254 |
254 |
$13K |
| D0603 |
|
900 |
900 |
$13K |
| D0272 |
Bitewings - two radiographic images |
777 |
777 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
254 |
254 |
$8K |
| D0330 |
Panoramic radiographic image |
259 |
258 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
131 |
84 |
$8K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
52 |
12 |
$6K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
52 |
12 |
$5K |
| D0145 |
Oral evaluation for a patient under three years of age |
79 |
79 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
87 |
52 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
213 |
206 |
$3K |
| D0350 |
|
234 |
124 |
$2K |
| D9430 |
|
42 |
41 |
$1K |
| D0274 |
Bitewings - four radiographic images |
27 |
27 |
$583.20 |