| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
7,306 |
7,061 |
$95K |
| D0120 |
Periodic oral evaluation - established patient |
5,461 |
5,256 |
$52K |
| D1206 |
Topical application of fluoride varnish |
7,914 |
7,623 |
$51K |
| D0272 |
Bitewings - two radiographic images |
5,600 |
5,395 |
$34K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,582 |
1,094 |
$28K |
| D0220 |
Intraoral - periapical first radiographic image |
4,720 |
4,512 |
$25K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
845 |
379 |
$25K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,429 |
2,350 |
$18K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,102 |
3,731 |
$17K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,110 |
597 |
$13K |
| D7140 |
Extraction, erupted tooth or exposed root |
710 |
376 |
$12K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
534 |
221 |
$12K |
| D1351 |
Sealant - per tooth |
2,882 |
859 |
$12K |
| D0330 |
Panoramic radiographic image |
1,206 |
1,167 |
$8K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,184 |
2,007 |
$7K |
| D0274 |
Bitewings - four radiographic images |
830 |
792 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
500 |
443 |
$4K |
| D1110 |
Prophylaxis - adult |
398 |
366 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
273 |
268 |
$683.16 |
| D0603 |
|
2,368 |
2,260 |
$0.00 |
| D0602 |
|
195 |
192 |
$0.00 |
| D0601 |
|
45 |
43 |
$0.00 |