| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
5,203 |
5,187 |
$180K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,080 |
1,373 |
$163K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,225 |
889 |
$144K |
| D1206 |
Topical application of fluoride varnish |
5,795 |
5,775 |
$128K |
| D0120 |
Periodic oral evaluation - established patient |
4,116 |
4,108 |
$106K |
| D9248 |
|
1,075 |
1,057 |
$95K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,735 |
2,595 |
$81K |
| D0230 |
Intraoral - periapical each additional radiographic image |
7,740 |
3,768 |
$75K |
| D7140 |
Extraction, erupted tooth or exposed root |
909 |
655 |
$60K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
912 |
728 |
$59K |
| D0220 |
Intraoral - periapical first radiographic image |
4,285 |
4,214 |
$54K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
605 |
502 |
$52K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,576 |
1,568 |
$47K |
| D1110 |
Prophylaxis - adult |
894 |
890 |
$39K |
| D1351 |
Sealant - per tooth |
1,116 |
457 |
$38K |
| D0272 |
Bitewings - two radiographic images |
1,529 |
1,525 |
$28K |
| D0274 |
Bitewings - four radiographic images |
946 |
944 |
$26K |
| D0330 |
Panoramic radiographic image |
469 |
468 |
$22K |
| D0140 |
Limited oral evaluation - problem focused |
588 |
579 |
$14K |
| D0145 |
Oral evaluation for a patient under three years of age |
372 |
369 |
$9K |
| D2332 |
|
32 |
27 |
$3K |
| D1354 |
|
262 |
105 |
$3K |
| D2331 |
|
15 |
13 |
$1K |
| D2330 |
|
14 |
12 |
$932.68 |