| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,233 |
2,222 |
$96K |
| D1351 |
Sealant - per tooth |
4,593 |
963 |
$86K |
| D1206 |
Topical application of fluoride varnish |
2,320 |
2,312 |
$71K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
940 |
543 |
$63K |
| D0120 |
Periodic oral evaluation - established patient |
1,728 |
1,723 |
$42K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
475 |
316 |
$25K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,016 |
974 |
$25K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
208 |
138 |
$21K |
| D1353 |
|
1,828 |
390 |
$17K |
| D7140 |
Extraction, erupted tooth or exposed root |
244 |
145 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
502 |
498 |
$12K |
| D0272 |
Bitewings - two radiographic images |
1,082 |
1,078 |
$10K |
| D0603 |
|
1,288 |
1,281 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
1,873 |
1,860 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
144 |
143 |
$6K |
| D0274 |
Bitewings - four radiographic images |
494 |
492 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,745 |
1,728 |
$5K |
| D1110 |
Prophylaxis - adult |
134 |
132 |
$4K |
| D0601 |
|
366 |
365 |
$3K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
21 |
17 |
$1K |
| D0602 |
|
70 |
68 |
$620.00 |
| D0145 |
Oral evaluation for a patient under three years of age |
12 |
12 |
$540.00 |