| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
15,966 |
15,947 |
$692K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
7,349 |
3,117 |
$609K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
5,475 |
1,982 |
$598K |
| D1351 |
Sealant - per tooth |
18,566 |
3,431 |
$576K |
| D1206 |
Topical application of fluoride varnish |
15,985 |
15,957 |
$445K |
| D0120 |
Periodic oral evaluation - established patient |
12,325 |
12,315 |
$417K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
4,268 |
2,224 |
$306K |
| D7140 |
Extraction, erupted tooth or exposed root |
3,211 |
1,732 |
$243K |
| D0272 |
Bitewings - two radiographic images |
7,085 |
7,057 |
$137K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
5,332 |
5,252 |
$130K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
1,769 |
806 |
$118K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,509 |
3,502 |
$114K |
| D0140 |
Limited oral evaluation - problem focused |
2,386 |
2,362 |
$105K |
| D0330 |
Panoramic radiographic image |
1,613 |
1,610 |
$92K |
| D0603 |
|
7,145 |
7,135 |
$69K |
| D0274 |
Bitewings - four radiographic images |
1,954 |
1,951 |
$47K |
| D0220 |
Intraoral - periapical first radiographic image |
3,338 |
3,316 |
$33K |
| D1110 |
Prophylaxis - adult |
457 |
455 |
$24K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,339 |
2,294 |
$17K |
| D0145 |
Oral evaluation for a patient under three years of age |
432 |
429 |
$16K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
149 |
102 |
$14K |
| D0601 |
|
1,003 |
1,003 |
$10K |
| D9999 |
Unspecified adjunctive procedure, by report |
36 |
29 |
$6K |
| D0602 |
|
604 |
604 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
298 |
298 |
$475.00 |
| D9420 |
|
64 |
54 |
$120.00 |