| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
15,484 |
15,360 |
$690K |
| D0120 |
Periodic oral evaluation - established patient |
14,155 |
14,050 |
$504K |
| D1351 |
Sealant - per tooth |
14,785 |
3,637 |
$360K |
| D1206 |
Topical application of fluoride varnish |
18,980 |
18,851 |
$359K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,478 |
649 |
$249K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,105 |
1,668 |
$236K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,308 |
2,285 |
$113K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
3,948 |
3,788 |
$102K |
| D9248 |
|
389 |
360 |
$89K |
| D0330 |
Panoramic radiographic image |
1,951 |
1,944 |
$89K |
| D0603 |
|
10,850 |
10,746 |
$78K |
| D7111 |
|
1,120 |
574 |
$73K |
| D7140 |
Extraction, erupted tooth or exposed root |
913 |
430 |
$66K |
| D0272 |
Bitewings - two radiographic images |
4,673 |
4,641 |
$57K |
| D0140 |
Limited oral evaluation - problem focused |
1,750 |
1,706 |
$35K |
| D0220 |
Intraoral - periapical first radiographic image |
2,725 |
2,632 |
$30K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
292 |
228 |
$24K |
| D0602 |
|
2,195 |
2,186 |
$20K |
| D0274 |
Bitewings - four radiographic images |
840 |
823 |
$16K |
| D2390 |
|
77 |
31 |
$15K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
132 |
81 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,566 |
791 |
$8K |
| D1110 |
Prophylaxis - adult |
42 |
41 |
$2K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
16 |
12 |
$770.00 |