| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,704 |
3,704 |
$165K |
| D1206 |
Topical application of fluoride varnish |
3,607 |
3,607 |
$113K |
| D0120 |
Periodic oral evaluation - established patient |
3,246 |
3,246 |
$81K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,134 |
729 |
$79K |
| D1351 |
Sealant - per tooth |
3,525 |
946 |
$71K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,477 |
1,439 |
$36K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
567 |
419 |
$31K |
| D0603 |
|
2,323 |
2,323 |
$23K |
| D0272 |
Bitewings - two radiographic images |
2,096 |
2,095 |
$21K |
| D0220 |
Intraoral - periapical first radiographic image |
3,061 |
3,061 |
$15K |
| D1353 |
|
1,460 |
368 |
$15K |
| D9920 |
|
400 |
396 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,835 |
2,835 |
$9K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
79 |
41 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
148 |
102 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
131 |
131 |
$6K |
| D0274 |
Bitewings - four radiographic images |
386 |
386 |
$5K |
| D0145 |
Oral evaluation for a patient under three years of age |
120 |
120 |
$3K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
34 |
14 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
65 |
65 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
132 |
132 |
$2K |
| D0601 |
|
63 |
63 |
$630.00 |