| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
5,770 |
5,459 |
$250K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
6,445 |
6,108 |
$154K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,564 |
761 |
$96K |
| D1208 |
Topical application of fluoride, excluding varnish |
6,481 |
6,129 |
$88K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
649 |
209 |
$65K |
| D0272 |
Bitewings - two radiographic images |
2,442 |
2,307 |
$40K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
525 |
192 |
$30K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
712 |
628 |
$24K |
| D0330 |
Panoramic radiographic image |
659 |
625 |
$24K |
| D7140 |
Extraction, erupted tooth or exposed root |
482 |
182 |
$20K |
| D1110 |
Prophylaxis - adult |
426 |
410 |
$18K |
| D1351 |
Sealant - per tooth |
1,022 |
297 |
$17K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
231 |
121 |
$17K |
| D0220 |
Intraoral - periapical first radiographic image |
1,735 |
1,593 |
$16K |
| D0140 |
Limited oral evaluation - problem focused |
429 |
395 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,287 |
820 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
68 |
55 |
$4K |
| D0274 |
Bitewings - four radiographic images |
41 |
41 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
24 |
24 |
$241.73 |