| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,490 |
3,488 |
$157K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,620 |
915 |
$113K |
| D1206 |
Topical application of fluoride varnish |
3,585 |
3,583 |
$112K |
| D1351 |
Sealant - per tooth |
5,030 |
1,311 |
$100K |
| D0120 |
Periodic oral evaluation - established patient |
2,719 |
2,716 |
$68K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,162 |
735 |
$64K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,904 |
1,819 |
$47K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
223 |
112 |
$22K |
| D7140 |
Extraction, erupted tooth or exposed root |
434 |
260 |
$22K |
| D9920 |
|
760 |
730 |
$21K |
| D0272 |
Bitewings - two radiographic images |
2,113 |
2,107 |
$21K |
| D0603 |
|
2,100 |
2,097 |
$21K |
| D1353 |
|
1,629 |
394 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
3,055 |
3,043 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
547 |
547 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,850 |
2,844 |
$10K |
| D0274 |
Bitewings - four radiographic images |
474 |
474 |
$6K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
57 |
38 |
$4K |
| D0145 |
Oral evaluation for a patient under three years of age |
113 |
113 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
58 |
58 |
$3K |
| D0602 |
|
154 |
154 |
$2K |
| D0601 |
|
76 |
76 |
$760.00 |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$540.00 |