| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,620 |
2,598 |
$91K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
891 |
544 |
$84K |
| D0120 |
Periodic oral evaluation - established patient |
2,442 |
2,412 |
$66K |
| D1351 |
Sealant - per tooth |
2,380 |
465 |
$63K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,162 |
1,962 |
$61K |
| D0145 |
Oral evaluation for a patient under three years of age |
391 |
388 |
$54K |
| D1206 |
Topical application of fluoride varnish |
3,411 |
3,379 |
$47K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
338 |
45 |
$44K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
544 |
372 |
$40K |
| D1110 |
Prophylaxis - adult |
610 |
596 |
$30K |
| D0220 |
Intraoral - periapical first radiographic image |
2,376 |
2,339 |
$25K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
936 |
898 |
$24K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
716 |
705 |
$23K |
| D0272 |
Bitewings - two radiographic images |
1,246 |
1,237 |
$22K |
| D0210 |
Intraoral - complete series of radiographic images |
313 |
313 |
$20K |
| D0274 |
Bitewings - four radiographic images |
679 |
664 |
$17K |
| D0330 |
Panoramic radiographic image |
720 |
711 |
$10K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
91 |
29 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
328 |
326 |
$6K |
| D1354 |
|
42 |
15 |
$409.48 |
| D0603 |
|
4,069 |
4,021 |
$0.01 |